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OF  ILLINOIS 
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6 18. Z. 

"R. 


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PROCESS  OF  PARTURITION. 

ILLUSTRATED  BY 


ONE  HUNDRED  AND  FORTY-TWO  FIGURES. 


Plate  I. 


PRINCIPLES  AND  PRACTICE 

'*EBS|Tr  OF  ILLINOIS 

OP 

OBSTETRIC  MEDICINE  AND  SURGERY, 


IN  REFERENCE  TO  THE 


PROCESS  OF  PARTURITION. 

Ullustratett  fig  ©tie  J&un&rrtJ  attb  forta=ttoo  fCsures. 


BY 


FRANCIS  H.  RAMSBOTHAM,  M.  D. 


CONSULTING  PHYSICIAN  IN  OBSTETRIC  CASES  TO,  AND  LECTURER  ON  OBSTETRIC  AND 
FORENSIC  MEDICINE  AT,  TIIE  LONDON  HOSPITAL,  PHYSICIAN  TO  THE 
ROYAL  MATERNITY  CHARITY, 

OBSTETRIC  PHYSICIAN  TO  THE  EASTERN  AND  TOWER  HAMLETS’  DISPENSARIES. 


FIRST  AMERICAN  EDITION  REVISED. 


PHILADELPHIA: 

LEA  & BLANCHARD. 


according  to  Act  of  Congress,  in  the  year  1842,  by  LEA  & BLANCHARD, 
in  the  Clerk’s  Office  of  the  District  Court  of  the  Eastern  District  of  Pennsylvania. 


GRIGGS  & CO.,  PRINTERS. 


THE  LIBRARY  OF  THE 
SEP  2 5 1934 

UNIVFRSITY  OF  ILLINOIS 


LIS.Z 

Klip 

\s+z~ 


JOHN  RAMSBOTHAM,  M.  D., 

CONSULTING  PHYSICIAN  TO  THE  ROYAL  MATERNITY  CHARITY  J 
LATE  LECTURER  ON  OBSTETRIC  MEDICINE  AT  THE  LONDON  HOSPITAL,  &C.  &C. 

Sir, 

Permit  me  to  inscribe  to  you  the  following  pages,  the  fruits  principally 
of  your  instructions,  as  a tribute  justly  due  to  your  station  in  the  medical 
profession,  and  an  earnest  of  the  reverential  feelings  with  which  you  are 
regarded  by 

A MOST  GRATEFUL  SON. 


Q 


5 1314 


DIRECTIONS  TO  THE  BINDER 


FOR 

PLACING  THE  PLATES. 


Plate  I.  To  face  the  Title. 

II. 

- 

- 

page  18 

III. 

. 

. 

. 

20 

IV.  . 

30 

V. 

. 

. 

36 

VI.  - 

. 

38 

VII. 

. 

40 

VIII. 

- 

44 

IX. 

. 

50 

X.  - 

. 

54 

XI. 

58 

XII.  - 

. 

62 

XIII. 

. 

66 

XIV.  - 

. 

70 

XV. 

. 

74 

XVI.  - 

76 

XVII. 

. 

78 

XVIII.  - 

. 

82 

XIX. 

. 

86 

XX.  . 

. 

88 

XXI. 

. - 

to  follow  Plate  XX. 

XXII.  - 

. 

106 

XXIII. 

. 

108 

XXIV.  - 

to  follow  Plate  XXIII. 

XXV. 

. 

110 

XXVI.  - 

. 

112 

XXVII. 

. 

122 

XXVIII. 

. 

152 

XXIX. 

_ 

156 

XXX.  - 

. 

160 

XXXI. 

180 

XXXII. 

. 

202 

XXXIII. 

. 

218 

XXXIV. 

232 

XXXV. 

. 

250 

XXXVI. 

. 

252 

XXXVII. 

- 

256 

XXXVIII. 

. 

284 

XXXIX. 

- 

286 

XL.  . 

. 

288 

XLI. 

. 

290 

XLII. 

to  follow  Plate  XLI. 

XLIII. 

. 

304 

XLIV. 

. 

306 

XLV. 

- 

322 

XLVI. 

. 

324 

XLVII. 

- 

340 

XLVIII. 

- 

352 

XLIX. 

. 

- 

. 

- 

• 

372 

L. 

. 

430 

LI. 

. 

. 

. 

. 

. 

. 

. 

440 

LII. 

- 

- 

■ 

448 

DESCRIPTION  OF  THE  PLATES. 


Plate 

Fig. 

I. 

1. 

Outline  of  the  male  form. 

2. 

Outline  of  the  female  form. 

II. 

3. 

Os  Innominatum,  left  side,  in  early  life.  View  of  the 

inner  surface. 

4. 

Os  Innominatum  in  adult.  View  of  outer  surface. 

5. 

Os  Innominatum  in  adult.  View  of  inner  surface. 

6. 

Sacrum. 

* 7. 

Trunk  and  pelvis  of  a human  subject. 

8. 

Pelvis  of  a cat. 

III. 

9. 

Front  view  of  the  male  skeleton  pelvis. 

10. 

Front  view  of  the  female  skeleton  pelvis. 

11* 

Brim  of  the  female  pelvis. 

IV. 

12. 

Outlet  of  the  female  pelvis. 

13. 

Section  of  a male  skeleton  pelvis. 

14. 

Section  of  a female  skeleton  pelvis. 

y. 

15. 

Front  view  of  the  foetal  skull. 

10. 

Side  view  of  the  foetal  skull. 

17. 

View  of  the  anterior  fontanelle. 

18. 

View  of  the  sagittal  suture. 

19. 

View  of  the  occiput  and  posterior  fontanelle. 

VI. 

20,  21.  Slightly  deformed  pelves. 

22. 

Excessively  deformed  pelvis — Angular  distortion. 

VII. 

23,  24, 25.  Excessively  deformed  pelves — Angular  distor- 

tion. 

VIII. 

26,  27.  Excessively  deformed  pelves — Elliptical  distortion. 

IX. 

28. 

Pelvimeters  applied. 

Vlll 


DESCRIPTION  OF  THE  PLATES. 


Plate 

Fig. 

IX. 

29. 

Mode  of  measuring  a deformed  pelvis  by  the  index 
finger. 

30. 

Mode  of  measuring  a deformed  pelvis  by  the  whole 
hand. 

31. 

Mode  of  measuring  a deformed  pelvis  by  the  first  two 
fingers  of  the  left  hand. 

X, 

32. 

External  organs  of  generation  in  the  female. 

XI. 

33. 

Internal  organs  of  generation  in  the  female. 

34. 

Lateral  section  of  the  unimpregnated  uterus. 

35. 

Infantile  uterus  laid  open. 

36. 

Cavity  of  the  adult  uterus. 

XII. 

37. 

Ovary  without  a corpus  luteum. 

38. 

External  surface  of  the  ovary  with  a corpus  luteum. 

39,  < 

40,  41,  43.  True  corpora  lutea. 

42,  44.  False  corpora  lutea. 

XIII. 

45. 

Lateral  section  of  the  female  pelvis,  with  its  contents. 

46. 

View  of  the  floor  of  the  female  pelvis — regarding  it 
from  the  abdomen. 

XIV. 

47. 

Arteries  of  the  uterus. 

48. 

Nerves  of  the  uterus. 

XV. 

49. 

Portion  of  the  deciduous  membrane;  face  next  the 

ovum. 

50. 

Portion  of  the  deciduous  membrane;  face  next  the 
uterus. 

51. 

Double  layer  of  deciduous  membrane,  surrounding  an 
ovum  about  seven  weeks  old. 

52, 

53.  Ova  about  five  and  six  weeks  old ; the  former 
shows  the  filamentous  vessels  entirely  surround- 
ing it;  the  latter  partially. 

54. 

An  ovum  about  eight  weeks  old  showing  the  placenta 
when  first  formed. 

55. 

A blighted  ovum,  about  seven  or  eight  weeks  old. 

XVI. 

56. 

An  ovum  of  five  months  of  age  within  the  uterus. 

57. 

An  ovum  of  five  months  of  age,  enclosed  in  the  am- 
nion, which  is  unopened  and  separated  from  chorion 
and  placenta. 

58. 

Umbilical  vesicle  in  the  ovum  between  five  and  six 
weeks  old. 

59. 

Umbilical  vesicle  in  an  ovum  between  seven  and  eight 
weeks  old. 

XVII. 

60. 

Placenta,  foetal  face. 

DESCRIPTION  OF  THE  PLATES. 


IX 


Plate 

Fig. 

XVII. 

61. 

Placenta,  maternal  face. 

62. 

Longitudinal  division  of  a portion  of  the  funis  umbili- 
calis,  to  show  the  cells  containing  the  gelatine. 

XVIII. 

63. 

Twin  placentae. 

64. 

Battledore  placenta,  taken  from  an  injected  specimen. 

65. 

Arteries  of  the  umbilical  cord  twisted. 

XIX. 

66. 

Gravid  uterus  opened,  to  show  the  natural  position  of 
the  foetus  within  the  cavity. 

XX. 

67. 

Uterus  at  the  commencement  of  the  fifth  month  of 
pregnancy. 

68. 

The  os  uteri  at  the  end  of  the  third  month  of  gestation. 

69. 

The  os  uteri  at  the  end  of  six  months. 

70. 

The  os  uteri  at  the  end  of  nine  months. 

XXL 

71. 

Gravid  uterus  at  the  full  period  of  pregnancy  in  the 
abdominal  cavity. 

XXII. 

72. 

Side  view  of  the  uterus  and  pelvic  cavity;  the  os  uteri 
entirely  dilated;  the  membranes  protruding  into  the 
vagina  as  in  labour. 

73. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  to  right  ilium. 

74. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  to  left  ilium. 

XXIII. 

75. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  to  right  sacro-iliac  synchondrosis. 

76. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  to  left  sacro-iliac  synchondrosis. 

77. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  to  left  groin. 

XXIV. 

78. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  to  right  groin. 

79. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  impinging  on  the  sacral  promontory. 

80. 

Foetal  skull  adapted  to  skeleton  pelvis,  vertex  present- 
ing, forehead  above  the  symphysis  pubis. 

XXV. 

81. 

Labour  considerably  advanced;  head  in  the  pelvis; 
the  face  to  right  sacro-iliac  synchondrosis. 

82. 

Face  turned  into  the  sacral  cavity;  vertex  external; 
forehead  distending  the  perineum,  the  right  shoulder 
entering  the  pelvis  towards  the  right  groin,  the  left 
towards  the  left  sacro-iliac  symphysis. 

2 


X 


DESCRIPTION  OF  THE  PLATES. 


Plate  Fig. 
XXVL  83. 

84. 


XXVII.  85. 

86. 

XXVIII.  87. 


88. 

XXIX.  89. 
90. 

XXX.  91. 
92. 

XXXI.  93. 
94. 

XXXII.  95. 

96. 

XXXIII.  97. 

98. 

99. 

XXXIV.  100. 

101. 

102. 

XXXV.  103. 
104. 


Perineum  distended ; the  vertex  protruded  between  the 
labia. 

Head  expelled;  face  turned  to  the  right  thigh;  the 
right  shoulder  behind  the  symphysis  pubis ; the  left 
occupying  the  sacral  cavity. 

Examination  in  labour ; index  finger  of  the  right  hand, 
the  os  uteri  just  opening. 

Examination  in  labour,  with  two  fingers  of  the  left 
hand,  os  uteri  more  dilated. 

The  forehead  passing  under  the  pubes ; the  shoulders 
occupying  the  cavity  of  the  sacrum ; the  original 
presentation  having  been  with  the  face  to  the  right 
groin. 

Brow  presentation,  adapted  to  a skeleton  pelvis. 

Face  presentation  adapted  to  a skeleton  pelvis. 

Chin  appearing  under  the  pubes ; the  original  presen- 
tation having  been  that  of  the  face. 

Ear  presentation  adapted  to  a skeleton  pelvis. 

An  enlarged  ovary,  blocking  up  the  pelvic  cavity  in 
labour. 

A polypus  occupying  the  pelvic  cavity  in  labour. 

The  bladder  distended  and  prolapsed  before  the  head 
of  the  child. 

A dropsical  head. 

A dropsical  head  adapted  to  a skeleton  pelvis. 

Short  forceps,  a.  The  instrument  closed,  b.  Back 
view  of  a single  blade. 

Forceps  applied  to  the  head,  the  face  being  the  hollow 
of  the  sacrum. 

Forceps  applied  to  the  face  towards  the  right  sacro- 
iliac synchondrosis. 

Forceps  applied  to  the  face  towards  the  right  groin ; 
the  bladder  slightly  distended. 

Lowder’s  Vectis. 

Application  of  the  vectis  in  a face  presentation,  the 
chin  impinging  under  the  symphysis  pubis. 

Long  forceps,  a.  The  instrument  closed,  b.  Back 
view  of  a single  blade. 

Long  forceps  applied ; the  right  brow  towards  the  right 
sacro-iliac  symphysis. 


DESCRIPTION  OF  THE  PLATES. 


XI 


Plate 

XXXV. 

XXXVI. 

xxxVii. 

XXXVIII. 

XXXIX. 

XL. 


XLI. 


Fig. 

105. -  Smellie’s  scissors.  «.•  Front  view.  b.  Side  view  of 

the  point. 

106.  Crotchet. 

107.  Blunt  hook. 

108.  Craniotomy  forceps;  a the  entire  instrument;  b the 

cup  blade  with  indentations  to  receive  the  teeth  of 
the  other. 

109.  Davis’s  Osteotomist. 

110.  Craniotomy  by  means  of  Smellie’s  scissors ; the  pelvis 

distorted. 

111.  Craniotomy; — the  use  of  the  crotchet. 

112.  One  form  of  Prof.  Davis’s  guarded  crotchet;  a the 

instrument  closed,  b the  crotchet  blade  which  is  to 
be  fixed  on  the  outer  part  of  the  skull. 

113.  Craniotomy; — the  craniotomy  forceps  applied. 

114.  The  head  of  a premature  foetus  passing  through  the 

brim  of  a distorted  pelvis. 

115.  Breech  presentation  ; the  foetal  face  towards  the  mo- 

ther’s spine/ 

116.  Breech  passing  through  the  external  parts. 

117.  Feet  presentation;  the  back  of  the  foetus  towards  the 

mother’s  spine. 

118.  Knee,  foot,  and  funis  presentation. 

119.  The  breech  expelled;  the  right  hand  of  the  attendant 

engaged  in  drawing  down  a loop  of  the  umbilical 
cord.  The  foetus  had  here  been  placed  in  utero  with 
its  back  towards  the  mother’s  spine,  as  in  fig.  117. 
Plate  XXXIX. 

120.  To  exemplify  mala  praxis,  the  body  of  the  child  having 

been  extracted,  the  attendant  is  endeavouring  to 
draw  the  head  through  the  pelvic  brim,  with  the 
forehead  against  the  promontory  of  the  sacrum,  the 
occiput  above  the  symphysis  pubis; — the  long  dia- 
meter of  the  child’s  head  being  in  the  direction  of 
the  short  diameter  of  the  brim  of  the  pelvis. 

121.  Relieving  the  left  arm  from  the  pelvic  cavity,  the  right 

having  been  already  extracted. 

122.  Extracting  the  head  through  the  outlet  of  the  pelvis, 

the  point  of  the  index  finger  of  the  left  hand  being 
inserted  into  the  mouth,  the  first  two  fingers  of  the 
right  surrounding  the  neck. 


DESCRIPTION  OF  THE  PLATES. 


XI 1 


Plate 

Fig. 

XLII. 

123. 

Breech  presentation;  the  blunt  hook  applied. 

XLIII. 

124. 

The  left  shoulder  presenting ; the  membranes  unrup- 
tured. 

125. 

The  back  presenting ; the  liquor  amnii  evacuated. 

XLIY. 

126. 

Abdominal  presentation. 

127. 

Hand,  foot,  and  funis  presenting. 

XLY. 

128. 

Shoulder  presentation ; to  exemplify  the  spontaneous 
evolution. 

129. 

Exvisceration. 

XL  VI. 

130. 

Ramsbotham’s  decapitating  hook*  The  smaller  figure 
shows  a section  of  the  cutting  portion  of  the  blade. 

131. 

Decapitation. 

XL  VI I. 

132. 

Placental  presentation. 

XLYIII. 

133. 

Partial  placental  presentation,  the  membranes  unrup- 
tured. 

134. 

Partial  placental  presentation  the  membranes  broken. 

XLIX. 

135. 

Placenta  retained  in  utero  after  the  child’s  birth ; glo- 
bular contraction. 

136. 

Placenta  retained  in  utero  after  the  child’s  birth ; a 
part  of  the  fibres  of  the  fundus  contracted  round  a 
portion  of  the  placenta. 

137. 

Placenta  retained  in  utero  after  the  child’s  birth;  hour- 

glass contraction. 

L. 

138. 

The  funis  prolapsed  by  the  side  of  the  head. 

139. 

Hand  prolapsed  by  the  side  of  the  head. 

LI. 

140. 

Monstrosity.  Two  foetal  bodies  joined  together  by 

the  sternum  and  abdomen. 

141. 

Monstrosity,  with  two  heads,  four  arms,  and  two  legs. 

LII. 

142. 

Twins  in  utero ; the  head  of  one  presenting,  the  breech 
of  the  other. 

PREFACE. 


Should  any  apology  be  deemed  necessary  for  obtruding  on  the  medical 
public  a new  work  on  obstetric  science,  it  may,  perhaps,  be  furnished  by 
the  interest  which  that  department  of  medicine  has  acquired  of  late  years, 
and  the  attention  it  now  commands  from  the  profession.  The  numerous 
valuable  publications  on  the  subject  that  have  recently  issued  from  the 
press,  forcibly  demonstrate  the  high  position  it  has  attained  as  a part  of 
medical  studies ; and  it  is  confidently  hoped  that  the  present  addition  to  the 
stock  of  obstetric  literature,  drawn  up  on  a somewhat  novel  plan,  will  not 
be  considered  altogether  superfluous. 

This  branch  of  physic,  indeed,  has  struggled  against  far  greater  difficul- 
ties than  have  beset  the  general  practice  of  medicine  and  surgery ; for  both 
ignorance  and  prejudice  have  lent  their  aid  towards  retarding  its  advance- 
ment. On  the  one  hand,  it  has  had  to  contend  with  the  natural  prejudices 
that  females  themselves  must  entertain  against  admitting  a person  of  the  op- 
posite sex  to  undertake  the  duties  required  under  the  trying  time  of  labour ; 
and  on  the  other,  with  the  erroneous  belief  that  parturition,  being  a natural 
action,  would  be  accomplished  in  woman  with  equal  facility  and  safety  as 
in  the  brute  creation.  Arguments,  sufficiently  strong  and  numerous,  could 
be  adduced  to  prove  the  fallacy  of  the  latter  assumption,  but  they  are 
foreign  to  our  immediate  purpose.  And  although  the  change  has  been 
effected  but  slowly,  the  prejudice  existing  in  the  female  breast  has  now, 
happily  for  them,  given  way  to  a sense  of  the  security  they  enjoy  in  placing 
themselves  under  the  superintendence  of  well-educated  surgeons. 

The  continental  universities  took  the  lead  in  enrolling  midwifery , as  it  is 
called,  among  their  obligatory  studies ; and  most  of  the  British  institutions 
of  a like  nature  have  tardily  followed  in  their  steps.  It  cannot  be  neces- 
sary to  enforce  by  reasoning  the  propriety  of  the  regulations  they  have 


XIV 


PREFACE. 


adopted;  but  whatever  circumstances  may  have  impelled  them  to  such  de- 
cisions, cannot  be  devoid  of  interest*  and  are  therefore  worthy  of  being 
recorded. 

As  far  as  the  London  corporations  are  concerned,  much  may  be  attri- 
buted to  the  exertions  of  a society  established  in  1826,  under  the  title  of 
the  Obstetric  Society  of  London.  This  body  consisted  of  about  thirty 
members,  embracing,  with  the  exception  of  two  or  three,  all  the  then  pre- 
sent and  late  lecturers  on  obstetric  medicine  in  London,  besides  a few  other 
practitioners;  and  the  editor  of  this  work  acted  as  honorary  secretary. 
The  object  of  the  society  was  to  place  the  practice  of  obstetric  medicine 
on  a more  respectable  footing  than  it  had  hitherto  enjoyed.  It  was  pro- 
posed to  accomplish  this  by  inducing  the  Colleges  of  Physicians  and  Sur- 
geons of  this  city  to  abrogate  their  by-laws,  which  precluded  practitioners 
in  “ midwifery”  from  the  fellowship  of  the  one,  and  a seat  at  the  council- 
board  of  the  other;  and  by  requiring  the  College  of  Surgeons,  and  Society 
of  Apothecaries,  riot  only  to  make  obstetric  science'  the  subject  of  exami- 
nation, but  to  oblige  all  candidates  who  offered  themselves  for  their  diploma 
to  adduce  testimonials  of  having  diligently  applied  themselves  to  its  study. 

A lengthened  correspondence  passed  between  the  committee  and  the 
secretary  of  state  for  the  home  department,  as  also  with  the  London  me- 
dical corporations.  Sir  Robert  Peel,  at  that  time  at  the  head  of  the  Home 
Office  entered  v/armly  into  the  question,  honoured  a deputation  of  the 
society  with  an  interview,  put  himself  in  communication  with  the  medical 
corporations  on  the  subject  of  the  memorials  addressed  to  him,  and  allowed 
a great  part  of  the  correspondence  which  passed  between  them  and  the 
society  to  be  transmitted  through  his  office. 

All  the  objects  which  the  society  proposed  have  since  been  carried  into 
effect,  except  the  change  ill  the  constitution  of  the  council  of  the  College 
of  Surgeons;  and  thus,  to  the  perseverance  of  a very  few  members  of  the 
profession  may  justly  be  attributed  the  adoption  of  measures  fraught  with 
the  highest  possible  advantage  to  the  community,  inasmuch  as  they  tend 
to  enhance  the  acquirements  of  the  great  mass  of  English  practitioners. 


CONTENTS. 


Dedication  , 

Directions  to  the  binder 
Description  of  the  Plates 
Preface 

Of  the  pelvis  . 

Of  the  fcetal  head 
Of  deformed  pelves 
Pelvimeters 

Of  the  female  generative  organs 

external 

internal  . 

Of  the  gravid  uterus 

Of  Labour  .... 

I.  Of  natural  labour 

the  management  of  natural  labour 

II.  Of  difficult  labour 
lingering  labour 
instrumental  labour 

THE  CESARIAN  OPERATION 

THE  SlGAULTEAN  OPERATION 

THE  INDUCTION  OF  PREMATURE  LABOUR 

III.  Of  preternatural  labour 
Of  breech  presentations 
Of  transverse  presentations 


v 

vi 
* vii 

xiii 

17 

31 

37 

45 

51 

ib. 

55 

71 

89 

102 

116 

168 

ib. 

211 

363 

266 

373 

281 

282 

30] 


XVI 


CONTENTS. 


IV.  Of  complex  labours  .....  327 

1.  Haemorrhage  .....  ib. 

2.  Convulsions  ......  398 

3.  Rupture  of  the  uterus  . . . . 415 

4.  Lacerated  vagina  .....  425 

5.  Ruptured  bladder  .....  426 

6.  Collapse  ......  428 

7.  Prolapsed  navel-string  ....  430 

8.  Descent  of  the  hand  with  the  head  . . . 435 

9.  Monsters  ......  437 

10.  Plural  births  ......  445 

455 


Index 


OBSTETRIC  MEDICINE 


AND 

SURGERY. 


OF  THE  PELVIS. 


Plates.— II.,  III.,  IV. 

Before  the  mechanism  of  parturition  can  be  understood,  it  is  necessary 
to  describe  the  organs  subservient  to  the  process,  and  with  this  view  the 
bony  pelvis  first  offers  itself  to  the  attention. 

The  term  pelvis  is  applied  to  that  mass  of  bones  which,  placed  at  the 
bottom  of  the  spinal  column,  and  resting  on  the  inferior  extremities,  con- 
nects the  thighs  with  the  upper  part  of  the  trunk.  When  divested  of  its 
soft  structures,  this  organ  somewhat  resembles  a basin,  and  hence  its 
name ; for  the  Greeks  called  it  m Av|,  a wooden  utensil  of  bowl-form,  used 
for  domestic  purposes;  the  Latins  from  them  derived  the  word  pelvis, 
which  we  have  adopted.  In  many  of  the  older  anatomical  works  it  is 
described  as  “ the  basin,”  but  all  the  recent  authors  have  preferred  the 
more  classical  appellation  of  pelvis. 

Division  of  the  hones  of  the  pelvis . — In  the  adult  state  it  is  composed  of 
four  bones,  two  ossa  innominata,  which  form  the  parietes  at  the  side  and 
in  the  front;  the  os  sacrum  and  the  os  cozygis,  which  bound  the  cavity 
behind.  But  until  the  age  of  childhood  is  considerably  advanced,  many 
points  of  ossification  are  observed  in  each  of  these  bones,  separated  by 
intervening  portions  of  cartilage;  these  cartilaginous  septa  are  gradually 
absorbed  as  growth  advances,  and  ossific  matter  is  deposited  in  their 
stead  ; so  that  one  solid  bone  is  formed  of  what  originally  consisted  of 
many  pieces. 

This  arrangement  is  particularly  remarkable  in  the  os  innominaturt, 
which  during  the  period  of  infancy  is  divided  into  three  distinct  parts. 

3 


18 


OS  ILIUM. 


In  describing  the  os  innominatum,  therefore,  anatomists  have  preserved 
the  distinction  of  these  separate  bones,  marked  out  in  early  life ; and 
demonstrate  it  as  though  it  still  consisted  of  the  three  original  portions. 
To  the  superior  division  they  give  the  name  of  os  ilium ; Plate  II.,  fig.  3,(1) 
to  the  inferior  that  of  os  ischium ;{ 2)  and  to  the  anterior  that  of  os  pubis.{ 3) 

The  white  lines  in  the  figure,  drawn  from  the  os  innominatum  of  the 
left  side,  distinguish  with  sufficient  clearness  the  natural  division  of  the 
bone  in  the  young  subject. 

Figs.  4 & 5,  Plate  II.  represent  the  left  os  innominatum  of  the  adult. 
The  first  gives  a view  of  the  outer,  the  second  of  the  inner  surface. 

The  Os  Ilium,  Hip  or  Haunch  Bone,  is  the  largest  of  the  three  divisions 
of  the  os  innominatum  ; and  it  is  uppermost  in  position.  It  is  remarkable 
for  some  peculiarities,  which,  in  an  obstetrical  point  of  view,  as  well  as 
anatomically,  are  worthy  of  consideration.  It  has  an  outer  and  an  inner 
surface ; the  outer  is  called  dorsum,  Plate  II.  fig.  4 .(a)  and  may  be  said  to 
be  irregularly  convex : it  is  marked  by  eminences  and  depressions  indica- 
tive of  the  attachment  of  the  three  powerful  glutaei  muscles.  The  chief 
extent  of  the  inner  surface  is  concave  and  smooth,  and  is  called  the  venter. 
The  lower  portion,  the  base  or  body,  is  the  thickest  part  of  the  bone,  and 
enters  largely  into  the  composition  of  the  acetabulum, (&)  a cavity  for  the 
reception  of  the  head  of  the  femur, — in  conjunction  with  which  it  forms 
the  hip-joint.  Just  above  the  base  the  bone  narrows  into  a kind  of  neck, 
from  which  springs  the  ala  or  wing, (a)  rising  obliquely  upwards,  outwards, 
backwards,  and  forwards,  to  protect  and  support  the  lower  abdominal 
viscera.  The  ala  terminates  superiorly  in  a ridge,  running  along  its  whole 
extent,  called  the  crista  ilii , crest  or  spine  of  the  ilium. (c)  This  ridge  is 
tipped  with  a deep  layer  of  cartilage  in  the  child,  as  is  shown  in  Fig.  1. 
PI.  II.  To  different  parts  of  the  crest  are  attached  the  oblique  and  trans- 
verse abdominal  muscles,  the  latissimus  dorsi,  the  erector  spinae,  and  the 
quadratus  lumborum.  The  crista  ilii  ends  both  anteriorly  and  posteriorly  in  a 
jutting  prominence,  to  which  the  term  spinous  process  is  applied  ; beneath 
each  of  these  prominences  there  is  a slight  sinuosity;  and  below  them,  again, 
another  jutting  point  of  bone,  also  called  spinous  process : so  that  there 
are  four  spinous  processes  belonging  to  the  ilium ; an  anterior  superior, (d) 
an  anterior  inferior, (e)  a posterior  superior, (/)  and  a posterior  inferior. (g) 
From  the  anterior,  powerful  muscles  take  their  origin.  The  anterior  supe- 
rior spinous  process  gives  attachment  to  one  end  of  Poupart’s  or  Gimber- 
nat’s  ligament ; to  the  tensor  vaginas  femoris,  and  the  sartorius  muscles. 
From  the  anterior  inferior  arises  the  longer  portion  of  the  rectus  femoris. 
Into  the  posterior  are  inserted  strong  ligaments,  which  bind  this  bone  most 
firmly  to  the  sacrum.  Below  the  posterior  inferior  spinous  process  there 
is  a considerable  sinuosity  or  arch, {h)  forming,  when  the  bone  is  joined  to 


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OS  ISCHIUM. 


19 


the  sacrum,  a very  large  notch:  this  is  called  the  sciatic  notch.  But  in 
the  recent  pelvis  this  notch  is  perfected  into  two  foramina — an  upper  one, 
the  larger,  and  a lower  one,  the  smaller — by  ligaments,  hereafter  to  be 
described,  which  run  from  the  side  to  the  back  part  of  the  pelvis ; and 
therefore,  when  the  ligaments  are  preserved,  their  apertures  are  called  the 
sciatic  foramina.  Plates  III.,  and  IV.,  fig.  14,  Through  the  larger  of  these 
pass  the  gluteal,  sciatic,  and  pudic  arteries ; the  sciatic  and  pudic  nerves, 
and  the  pyriform  muscle.  Through  the  smaller  the  pudic  arteries  and 
nerve  re-enter  the  pelvis,  and  the  obturator  internus  muscle  passes  out. 

That  portion  of  the  internal  face  of  the  ilium,  which  is  smooth  and  con- 
cave, Plate  II.,  fig.  5y(/i)  supplies  a bed  for  the  reception  of  the  iliacus  internus 
muscle;  but  the  posterior  part(/)  is  very  rough,  and  marks  the  connexion 
between  the  ilium  and  the  sacrum.  This  union  forms  one  of  the  two  sacro- 
iliac symphyses , or  posterior  joints  of  the  pelvis,  there  being  one  on  each  side 
of  the  sacrum.  Between  the  ilium  and  sacrum,  at  this  junction,  is  interposed 
a piece  of  fibro-cartilage,  about  a sixth  or  eighth  of  an  inch  in  thickness,  so 
that  the  bones  are  separated  to  that  extent ; and  it  is  invariably  remarked, 
provided  the  joint  is  healthy,  that,  when  the  ligaments  are  cut,  and  the 
two  bones  forcibly  wrenched  asunder  after  death,  the  cartilage  adheres  to 
the  sacrum,  leaving  the  ilium  denuded.  In  structure  it  is  more  like  the 
intervertebral  substance  than  any  other  tissue  of  the  body : it  is  arranged 
in  concentric  layers,  and  is  softer  towards  its  posterior  edge  than  in  the 
front.  The  object  of  this  soft  elastic  pad  being  situated  in  this  place  is 
evidently  to  break  the  shock,  and  prevent  the  jarring  sensation  which  must 
otherwise  have  been  experienced,  in  the  violent  actions  of  the  body,  such 
as  running  and  leaping  ; and  it  may  also  act  as  a cement  in  glueing  the 
bones  together.  Traversing  the  inner  surface  horizontally,  there  is  a 
ridge,  which  divides  the  ala  from  the  lower  part,(m)  and  which  is  more 
evident  in  the  entire  pelvis,  forming  a portion  of  the  pelvic  brim , linea 
innominala,  or  linea  ilio-pectinea.  Plate  III.,  fig.  11. 

The  ilium  is  connected  to  the  ischium  and  pubes  in  the  acetabulum,  and 
to  the  sacrum  by  means  of  the  sacro-iliac  symphysis. 

Second  in  size  and  lowest  in  position  of  the  three  divisions  of  the  os 
innominatum,  is  the  Os  Ischium,  Os  Sedentarium,  or  seat  bone,  so  called 
from  being  that  portion  of  the  bone  on  which  we  rest  when  sitting.  It  is 
remarkable  for  a base  or  body,  a spinous  process , its  tuberosity,  and 
ascending  ramus.  The  base  is  the  thickest  part,  and  assists  even  more 
largely  than  the  base  of  the  ilium  in  the  formation  of  the  acetabulum. 
Immediately  below  the  base  there  is  a narrowed  portion  that  may  be 
called  the  neck,  and  arising  from  the  posterior  part  of  the  neck,  jutting 
backwards  and  inwards,  there  is  a thin  pyramidal  process,  somewhat  like 
the  point  of  a lancet,  to  which  the  appellation  of  spinous  process(n ) is  given. 


20 


OS  PUBIS. 


This  affords  attachment  to  one  fasciculus  of  the  sacro-sciatic  or  sacro- 
ischiatic  ligaments,  and  gives  origin  to  the  coxygeus  muscle,  which  is 
inserted  into  the  coxyx,  to  raise  that  bone.  This  spinous  process  is  an 
object  of  more  intense  interest  to  the  obstetrician  than  its  small  size  would 
lead  us  to  suppose;  because  it  is  sometimes  of  undue  length,  or  is  bent  too 
much  inwardly.  By  such  a construction,  the  capacity  of  the  outlet  is 
materially  encroached  upon  and  diminished,  and,  in  a proportionate 
degree,  the  passage  of  the  child’s  head  in  labour  is  retarded.  In  its 
descent  downwards  from  the  neck,  the  bone  bulges  out  into  a considerable 
protuberance,  the  tuber  ischii , or  tuberosity  of  the  ischium;  and,  rising 
obliquely  upwards,  forwards,  and  inwards,  a flat,  narrow  sheet  of  bone 
extends,  to  meet  a similar  piece  of  bone  sent  down  from  the  pubes, — the 
ramus  of  the  ischium. (p)  This  bone  is  also  rough  externally  and  smooth 
within : to  the  lowest  part  of  the  tuber  is  attached  one  end  of  the  other 
fasciculus  of  the  sacro-sciatic  ligament ; whilst  the  outer  portion  gives 
origin  to  the  semi-membranosus,  semi-tendinosus,  the  long  head  of  the 
biceps  flexor  cruris,  and  quadratus  femoris  muscles.  The  ischium  is  con- 
nected to  the  ilium  and  pubes  in  the  acetabulum : it  is  firmly  connected 
also  to  the  sacrum;  not  by  direct  junction  or  bony  union,  but  by  means  of 
the  ligaments  just  mentioned. 

The  smallest  of  the  three  divisions  of  the  os  innominatum  is  the  os 
pubis,  pecten,  or  share  bone,  situated  anteriorly.  It,  like  the  ilium  and 
ischium,  possesses  a base  or  body ; it  has  two  rami,  a horizontal  and  a 
descending  ramus , a spinous  process , and  a symphysis . The  base  is  its 
thickest  part,  and  contributes  but  in  a small  proportion  to  form  the  aceta- 
bulum. Just  anterior  to  the  base  there  is  a contracted  part,  the  neck,  and 
running  horizontally  forwards  and  inwards,  so  as  to  meet  its  fellow  of  the 
opposite  side,  a thin,  narrowed  piece  of  bone  is  thrown  out — the  horizontal 
ramus  of  the  pubes. (q)  This  terminates  in  a wider  sheet,  and  its  edge,  the 
point  of  junction  with  its  fellow  bone,  is  called  the  symphysis  pubis  :(r)  it  is 
the  anterior  joint  of  the  pelvis.  The  pubic  bones  are  not,  however,  in 
contact  here ; for  there  is  a considerable  thickness  of  the  same  kind  ot 
cartilaginous  matter  placed  between  them  as  is  found  at  the  sacro-iliac 
symphyses.  Some  anatomists  have  affirmed  that  there  is  a double  joint, 
one  on  each  side  of  the  central  cartilage ; others,  that  there  is  only  one  ; and 
others,  again,  that  although  occasionally  an  imperfect  synovial  membrane 
may  be  seen,  by  far  most  frequently  neither  can  a cavity  be  detected,  nor 
any  apparatus  indicative  of  the  presence  of  a joint : and  this  latter  seems 
to  be  the  idea  of  the  best  anatomists  of  the  present  day.  From  the  thick- 
ness of  the  interposed  substance,  a slight  lateral  motion  may  possibly  be 
allowed  to  the  bones,  even  in  the  healthy  state  of  the  parts;  but  the 
strength  of  the  ligaments,  both  within  and  without,  would  prevent  any 


fi.hl. 


% 


LitA.J°hi  Z ‘ 


OS  PUBIS. 


21 


considerable  movement.  Proceeding  from  the  symphysis,  in  a direction 
downwards,  outwards,  and  rather  backwards,  to  be  joined  by  ossific  union 
with  the  ramus  ischii,  there  is  another  flat,  thin,  and  narrow  sheet  of  bone 
— - the  descending  ramus  of  the  pubes.(s)  This  bone  is,  like  the  other  two, 
rough  externally,  and  smooth  within : from  the  outer  surface  some  of  the 
adductor  muscles  of  the  thigh  take  their  rise.  On  the  interior,  running 
along  the  upper  margin  of  the  horizontal  ramus,  there  is  a ridge,  some- 
times rather  sharp,  which  is  a part  of  the  brim  of  the  pelvis,  and  at  its 
inner  extremity  it  terminates  in  a little  eminence — the  spinous  process. (t) 
To  this  is  attached  the  pubic  end  of  Poupart’s  ligament,  near  it  the  pecti- 
neus;  the  oblique  and  transverse  muscles,  the  pyramidalis,  and  rectus  abdo- 
minis, are  also  inserted  into  different  portions  of  the  upper  edge  of  the 
pubes.  The  pubes  is  connected  with  the  ilium  and  ischium  in  the  aceta- 
bulum, with  the  ischium  at  the  junction  of  their  rami,  and  with  its  fellow 
bone  of  the  opposite  side  by  the  symphysis.* 

When  the  os  innominatum  is  again  regarded  as  a whole,  the  attention 
cannot  fail  to  be  arrested  by  a large  oval  aperture  in  the  fore  part,  formed 
by  the  ischium  and  pubes — th e thyroid  or  obturator  for amen.(u)  In  the 
recent  pelvis  it  is  almost  entirely  filled  up  by  the  obturator  ligament, 
which  consists  merely  of  two  layers  of  periosteum,  one  externally,  the 
other  within,  continued  from  the  bone  across  it.  The  space  is  entirely 
covered  by  this  extension  of  the  periosteum,  except  at  the  uppermost  part, 
where  a hole  is  left,  not  larger  than  would  permit  the  passage  of  a small 
bougie : through  it  the  obturator  vessels  and  nerve  escape  from  the  pelvis. 
This  ligament  supplies  the  place  of  bone ; for  the  obturator  externus,  one 
of  the  rotators  of  the  thigh,  arises  from  its  outer  surface.  It  appears  to 
be  placed  here  for  the  purpose  of  rendering  this  part  of  the  body  lighter 
than  it  would  be,  were  a thick  piece  of  bone  present  instead. 

There  is  another  point,  in  regard  to  these  three  divisions  of  the  os 
innominatum,  worthy  the  consideration  of  the  obstetrician ; namely,  the 
relation  which  each  bears  to  those  parts  of  the  pelvis,  hereafter  to  be  more 
particularly  described, — the  brim  and  outlet.  The  ilium  forms  a consi- 
derable share  of  the  brim,  but  none  of  the  outlet;  the  ischium  forms  a 
part  of  the  outlet,  but  none  of  the  brim ; while  the  pubes  enters  very 
largely  into  the  composition  of  both  the  brim  and  outlet:  so  that  the  ilium 
might  be  greatly  deformed,  and  yet  the  brim  alone  suffer ; a distorted 
ischium  would  only  involve  the  outlet ; but  if  the  pubes  were  of  vicious 
formation,  both  brim  and  outlet  must  necessarily  be  implicated. 

* The  term  pubes  was  applied  to  this  bone  in  consequence  of  its  intimate  connexion  with 
the  external  organs  of  generation ; and  that  of  peclen  from  its  fancied  resemblance  to  a comb, 
when  the  two  are  united. 


22 


OS  SACRUM. 


The  pelvic  cavity  is  bounded  posteriorly  by  the  os  sacrum , os  basilare, 
or  rump  bone , and  the  os  coxygis,  which  are  also  called  the  false  vertebrce. 

The  os  Sacrum,  os  Basilare,  is  the  largest  bone  in  the  vertebral 
column : in  form  it  is  triangular,  the  apex  of  the  pyramid  being  placed 
downwards,  and  rather  backwards,  the  base  upwards,  and  inclined  a 
little  forwards.  Its  specific  gravity  is  small ; indeed,  it  is  the  lightest  bone 
in  the  body  for  its  size,  and,  consequently,  rather  spongy  in  structure.  It 
possesses  four  surfaces — an  external,  an  internal,  and  two  lateral.  The 
inner  face  of  the  sacrum  and  coxyx  is  represented  in  Plate  II.  fig.  6.  The 
external  surface  is  convex  and  rough ; and  there  are  four  or  five  processes 
placed  below  each  other  in  a perpendicular  line,  more  strongly  marked  at 
the  upper  part  of  the  bone,  assimilated  to  the  spinous  processes  of  the 
vertebrm;  they  may  therefore  be  called  the  spinous  processes  of  the 
sacrum . The  bone  indeed  appears,  as  it  were,  an  imperfect  continua- 
tion of  the  vertebral  column ; the  peculiarities  of  the  vertebrce  becoming 
less  evident,  and  dwindling  away  by  degrees  in  the  sacrum  as  they 
descend.  Anterior  to  this  series  of  processes,  there  is  a hollow  cavity 
extending  the  whole  length  of  the  bone — a continuation  of  the  spinal  canal 
— for  the  reception  of  the  Cauda  equina , which  is  the  inferior  portion  of 
the  spinal  marrow.  Four  pairs  of  holes  are  seen,  one  on  the  side  of  each 
spinous  process,  communicating  with  this  canal : these  are  for  the  trans- 
mission of  small  nerves  from  the  cauda  equina  to  the  soft  parts  covering 
the  sacrum  and  structures  adjacent.  Internally  the  sacrum  is  smooth, 
resembling  in  this  respect  the  other  bones  of  the  pelvis,  and  concave. 
Four  white  lines,  generally  rather  eminent,  run  horizontally  across  it, 
indicating  the  situation  of  cartilage  in  early  life,  by  which  the  bone  was 
divided  into  five  distinct  pieces.  There  are  also  four  pairs  of  holes 
within ; one  at  the  extremity  of  each  of  these  white  lines,  for  the  trans- 
mission of  nervous  filaments,  to  form  a portion  of  the  great  sciatic  nerve, 
as  well  as  to  supply  the  organs  contained  within  the  pelvis.  The  concave 
plane — the  cavity  or  hollow  of  the  sacrum  (a) — varies  in  regard  to  the  seg- 
ment of  the  circle  which  it  forms  in  different  individuals ; and  if  it  be  too 
straight,  or  too  much  curved,  it  will  equally  impede  the  ready  passage  of  the 
child’s  head  in  labour.  The  centre  of  the  upper  edge  of  the  bone  projects 
forward ; so  that  in  its  natural  position  this  part  looks  somewhat  over  the 
cavity,  and  diminishes  the  space  at  the  brim.  This  is  called  the  promi- 
nence or  promontory  of  the  sacrum. (b)  On  it  the  last  lumbar  vertebra 
rests,  a portion  of  intervertebral  substance  being  placed  between  them  ; and 
it  supports  the  whole  weight  of  the  trunk,  head,  and  superior  extremities. 
When  the  brim  of  the  pelvis  is  distorted,  the  irregularity  of  shape  is 
almost  always  attributable  to  the  prominence  of  the  sacrum,  together. 


OS  C O X Y G I S. 


23 


perhaps,  with  the  last  lumbar  vertebra  being  thrown  too  far  forwards,  and 
too  closely  approaching  the  pubes.  The  entrance  to  the  cavity  is  thus 
preternaturally  constricted ; and  the  diminution  of  space  in  this  way  pro- 
duced is  one  of  the  most  common  causes  of  lingering  labour  met  with  in 
this  city. 

The  lateral  surfaces(c)  are  very  rough,  and  correspond  in  extent  and 
irregularity  with  that  part  of  the  inner  face  of  the  ilium  which  forms  the 
sacro-iliac  symphysis. 

This  bone  is  connected  at  its  upper  part  to  the  last  lumbar  vertebra, 
through  the  intervention  of  a layer  of  intervertebral  substance,  to  the 
coxyx  below,  by  a moveable,  ginglimoid  joint,  and  to  the  ilium  on  each 
side  by  the  sacro-iliac  symphyses.  It  is  also  connected  to  the  ischium  by 
the  sacro-sciatic  ligaments. 

The  os  Coxygis*  ( d ) appears  like  a continuation  of,  or  an  appurtenance 
to,  the  sacrum ; but  it  is  of  much  importance  in  obstetrical  study.  It  was 
denominated  coxyx  from  its  resemblance  to  the  beak  of  the  cuckoo,  one 
of  the  hawk  tribe.  It  is  therefore,  as  the  name  would  imply,  in  shape 
hooked  and  pyramidal : the  base  is  placed  upwards,  the  apex  below.  The 
bone  is  divided  into  three,  and  sometimes  four,  distinct  portions,  which 
play  upon  each  other  by  separate  joints.  Externally  it  is  convex  and 
irregular,  concave  and  smooth  within,  and  terminates  in  a tapering  point, 
which  is  bent  forwards  in  the  ordinary  state  of  the  parts  to  support  the 
lower  end  of  the  rectum. 

The  coxygeal  joints  are  of  great  value  in  the  process  of  labour.  Their 
mobility  much  facilitates  the  exit  of  the  head,  by  enlarging  the  outlet  of 
the  pelvis  in  the  antero-posterior  direction.  The  increase  of  space  thus 
gained  amounts  to  an  inch  or  more;  for  the  point  of  the  bone  may  be 
bent  backwards  to  a line  continuous  with  the  sacrum,  or  even  beyond,  so 
as  to  form  an  angle  outwards,  Plate  IV,  fig.  14,  a . b. 

Occasionally,  indeed,  the  coxyx  becomes  anchelosed  to  the  sacrum, 
and  its  own  joints  also  are  destroyed  by  a deposition  of  osseous  matter 
between  the  separate  pieces,  so  that  their  mobility  is  lost,  and  the  bone 
becomes,  as  it  were,  a portion  of  the  sacrum  itself.  Such  a consolidation 
must  offer  a considerable  impediment  to  the  expulsion  of  the  head,  by 
contracting  the  pelvic  outlet : and  this,  though  a rare,  is  therefore  another 
cause  of  lingering  labour.  It  is  most  usually  met  with  in  women  bearing 
a first  child  late  in  life,  and  those  who  have  been  accustomed  to  sit  through 
the  principal  part  of  the  day,  as  is  the  case  with  milliners. 

When  the  coxyx  is  in  this  state,  it  will  sometimes,  break : this  may 
happen  as  well  during  a strong,  unaided  uterine  contraction,  as  under  the 


* Koxkv%,  a cuckoo. 


24 


FORM  OF  THE  PELVIS. 


employment  of  instruments.  The  occurrence  of  such  an  accident  may 
be  known, — perhaps,  by  the  attendant  being  sensible  of  the  part  having 
given  way,  while  his  hand  was  employed  protecting  the  perineum ; — and 
perhaps  by  his  hearing  the  noise  peculiar  to  bones  when  fractured.  I 
have  seen  three  cases  in  which  the  bone  broke,  or  the  anchelosed  joint 
gave  way ; in  none  of  these  did  any  permanent  injury  ensue.  There  was 
some  pain  and  inconvenience  for  a time,  but  eventually  re-union  was 
effected,  and  the  distress  occasioned  was  inconsiderable.  The  best  mode 
of  treating  such  a mischance  would  be  to  keep  the  patient  in  a state  of 
perfect  rest,  to  interdict  her  lying  on  her  back,  to  prevent,  if  possible,  any 
external  pressure  on  the  part,  and  to  keep  the  bowels  moderately  open. 
On  the  one  hand,  the  frequent  evacuation  of  the  rectum,  by  causing 
almost  constant  movement  of  the  fractured  portions  one  upon  the  other, 
would  interfere  with  ossific  union:  and,  again,  if  the  lower  bowels  became 
filled  with  hardened  faeces,  their  expulsion  would  probably  disturb  what- 
ever degree  of  reparation  might  have  been  procured.  Thus,  both  ex- 
tremes of  immoderate  action  and  excessive  constipation  must  be  avoided. 
In  the  management  of  the  patient,  not  only  should  our  object  be  directed 
towards  obtaining  a consolidation  of  the  separated  ends,  but  we  should 
also  endeavour  to  preserve  the  coxyx,  as  nearly  as  we  can,  in  a continu- 
ous line  with  the  sacrum ; for  it  is  evident,  that  if  the  junction  take  place 
while  the  point  of  that  bone  is  directed  grealy  forwards,  the  size  of  the 
pelvic  outlet  will  be  lessened  in  the  same  degree;  and  in  any  subsequent 
labour  a proportionate  difficulty  will  necessarily  exist.  The  coxyx  is 
called  venacularly  the  huckle  or  knuckle , and  sometimes  the  whistle-bone . 

Form  and  Dimensions  of  the  Pelvis. — When  we  examine  the  pelvis 
with  reference  to  labour,  we  must  attend  not  only  to  its  figure,  but  also 
to  its  dimensions,  and  the  bearings  which  its  axes  hold  in  regard  to 
each  other,  and  to  the  trunk  of  the  body.  We  observe  that  it  is  formed 
on  the  principle  of  the  double  arch,  which  structure  in  architecture  pos- 
sesses the  greatest  possible  degree  of  firmness  that  can  be  devised  for  the 
quantity  of  material  employed.  So  that  the  pelvis  combines,  to  an  emi- 
nent extent,  the  qualities  of  strength  and  lightness. 

Anatomists  distinguish  the  pelvis  into  two  grand  divisions,  the  true  and 
the  false  pelvis , considering  the  alee  ilii  to  constitute  the  false  portion. 
The  alas  ilii,  however,  are  of  trifling  interest  to  us  as  obstetricians ; for, 
unless  the  organ  be  inordinately  distorted,  they  have  little  or  no  influence 
over  the  process  of  parturition,  being  quite  out  of  the  way  of  the  head’s 
descent.  Obstetrically  it  is  divided  into  the  brim , or  superior  aperture, 
Plate  III.  fig.  11;  the  outlet,  or  inferior  aperture,  Plate  IV.  fig.  12;  and 
the  cavity  all  that  is  embraced  between  these  two ; and  the  peculiarities 
belonging  to  each  of  these  parts  offer  themselves  next  for  observation. 


FORM  OF  THE  PELVIS. 


25 


In  demonstrating  the  shape  and  size  of  the  female  pelvis,  it  is  the  cus- 
tom not  to  describe  any  particular  specimen  which  we  may  happen  to 
possess,  but  to  assume  a model  of  perfection,  which  we  consider  the 
standard;  so  symmetrically  formed,  as  would  most  completely  answer 
all  the  intentions  that  nature  has  assigned  to  it. 

The  Brim,  somewhat  oval  in  shape,  has  necessarily  two  diameters, — 
the  longest  from  side  to  side — the  shortest  in  the  centre  from  before  back- 
wards. The  regularity  of  the  oval  is  broken,  principally  by  the  jutting 
forwards  of  the  sacral  promontory  Plate  III.  fig.  11,  («,)  so  that  the  out- 
line represents,  in  some  measure,  the  heart,  as  painted  upon  playing  cards. 
But  this  resemblance  is  stronger  in  the  male  than  in  the  pelvis  of  the  oppo- 
site sex,  because  the  longest  diameter  in  the  male  pelvis  is  antero-poste- 
riorly,  Plate  III.  fig.  9,  while  in  the  female,  as  just  shown,  it  is  laterally, 
fig.  10. 

The  lateral , transverse , or  iliac  diameter,  measures  five  inches  and  a 
quarter,  Plate  III.  fig.  11,  (c.  d.;)  the  antero-posterior,  sacro-pubicf  or  con- 
jugate, measures  four  ( a . b.;)  the  two  oblique , or  diagonal , extending  from 
the  sacro-iliac  symphysis  to  the  ramus  of  the  pubes,  on  the  opposite  side 
of  the  body  (e./.,)  are  nearly  the  same  as  the  direct  lateral,  probably  not 
so  great  by  about  a quarter  of  an  inch.  These  admeasurements  are,  of 
course,  considerably  less  in  the  recent  pelvis  and  the  living  body,  in  con- 
sequence of  the  room  occupied  by  the  soft  structures ; we  must  allow  for 
their  lodgment  at  least  a quarter  of  an  inch  in  the  conjugate  diameter,  and 
half  an  inch  in  the  lateral,  to  which  extent  the  available  space  in  labour 
will  probably  be  diminished. 

It  has  been  much  disputed  whether  the  iliac  or  the  oblique  diameter 
should  be  considered  the  longest  ; we  shall  find,  I think,  that  in  by  far  the 
greatest  proportion  of  well-formed  pelves,  divested  of  the  softer  parts,  the 
iliac  measures  most ; but  when  the  contents,  linings,  and  muscles  are  pre- 
served, the  greatest  space  is  along  the  oblique  line. 

The  Cavity  is  observed  to  be  deep  behind,  shallow  in  front;  and  it  be- 
comes gradually  shallower  as  we  traverse  from  the  back  to  the  fore  part. 
The  greatest  depth  is  from  the  sacral  promontory  to  the  tip  of  the  coxyx, 
and  should  be  from  five  inches  and  a half  to  six  inches ; at  the  side,  from 
the  lowest  point  of  the  tuber  ischii  to  the  brim,  three  inches  and  a half; 
and  behind  the  symphysis  pubis,  one  and  a half,  Plate  IV.  fig.  14. 

The  Outlet  is  also  inclining  to  an  oval  shape,  but  is  even  of  greater 
irregularity  than  the  brim,  owing  principally  to  the  projection  of  the  tip 
of  the  coxyx  behind,  and  to  the  large  sinuosity  in  front,  the  arch  of  the 
pubes,  Plate  III.  fig.  10,  and  IV.  fig.  12,  ( a . b.)  In  extent  the  diameters 
of  the  outlet  are  nearly  the  same  as  at  the  brim ; in  situation  they  are  re- 
versed. Thus  the  long  diameter  is  from  before  backwards,  in  a line  ex- 
4 


26 


POSITION  OF  THE  PELVIS. 


tending  from  the  point  of  the  coxyx  to  the  under  edge  of  the  symphysis 
pubis,  Plate  IV.  fig.  12,  ( a .;)  and  when  the  bone  is  pressed  back  in  labour, 
this  measures  five  inches  or  more ; although,  in  the  ordinary  state  of  the 
parts,  the  extremity  being  directed  forwards,  its  utmost  extent  is  only  four. 
The  short  diameter  extends  laterally,  from  the  tuberosity  of  one  ischium 
to  that  of  the  other,  is  incapable  of  being  increased,  and  measures  four.  ( b .) 

The  outlet  is  bounded  by  the  tip  of  the  coxyx  at  the  back,  by  the  lower 
edge  of  the  under  fasciculus  of  the  sacro-sciatic  ligament  posteriorly  and 
laterally,  by  the  tuberosities  of  the  ischia  at  the  side,  by  the  ramus  of  the 
ischia  and  pubes  anteriorly  and  laterally,  and  by  the  symphysis  pubis  in 
front. 

The  position  of  the  pelvis , in  regard  to  the  trunk  of  the  body , is  neither 
perpendicular  to  the  horizon,  nor  horizontal,  but  oblique,  the  sacral  pro- 
montory being  raised  considerably  below  the  level  of  the  pubes ; so  that  a 
line  drawn  through  the  trunk,  in  a direction  of  its  axis,  would,  in  falling 
downwards,  strike  on  the  centre  of  the  symphysis  pubis.  It  is  by  resting 
on  this  bone  that  the  uterus  is  supported  during  the  latter  months  of  preg- 
nancy. Were  the  axes  of  the  trunk  and  pelvic  entrance  in  the  same  line, 
owing  to  the  upright  position  of  the  human  female,  the  womb,  towards  the 
close  of  gestation,  would  gravitate  low  into  the  pelvis,  and  produce  most 
injurious  pressure  on  the  contained  viscera ; while,  in  the  early  months, 
not  only  would  the  same  distressful  inconvenience  be  occasioned,  but 
there  would  be  great  danger  of  its  protruding  externally,  and  appearing 
as  a tumour  between  the  thighs,  covered  by  the  inverted  vagina.  In  the 
quadruped,  since  the  uterus  is  entirely  supported  by  the  abdominal  parietes, 
the  effects  of  gravity  on  the  pelvis  need  not  be  counteracted ; and  we 
therefore  find,  that  in  consequence  of  the  lumbar  vertebra  being  slightly 
arched  upwards,  the  axes  of  the  trunk,  brim,  and  outlet  are  placed  nearly 
in  a continuous  line. 

In  Plate  II.  fig.  7,  the  two  dotted  lines  mark  the  axes  of  the  trunk  and 
pelvic  entrance  in  the  human  subject.  In  fig.  8,  representing  the  skeleton 
of  a cat,  a single  line  runs  entirely  through  the  trunk  and  pelvis. 

The  pelvis  itself  has  also  two  axes,  one  of  the  brim,  which  is  down- 
wards and  backwards,  following  a direction  from  the  umbilicus  to  the 
coxygeal  extremity  of  the  spinal  column ; and  the  other  of  the  outlet, 
which  is  downwards  and  forwards,  from  the  promontory  of  the  sacrum 
to  the  central  space  between  the  tuberosities  of  the  ischia  ; so  that  a line 
drawn  through  the  brim,  in  the  direction  of  the  axis  of  the  brim,  would 
cross,  at  a considerable  angle,  another  line  drawn  in  the  direction  of  the 
axis  of  the  outlet,  Plate  IV.  fig.  14.  By  a knowledge  of  the  axes  of  the 
trunk  and  pelvic  entrance,  we  can  place  our  patient  under  labour 
in  the  posture  most  favourable  to  the  easy  descent  of  the  foetal  head 


PELVIC  JOINTS. 


27 


through  the  brim  into  the  cavity ; this  is  on  the  side,  (the  left  is  usually 
chosen  in  this  country,)  with  the  shoulders  thrown  forwards,  the  back 
bent  into  a curve,  the  thighs  drawn  up  towards  the  abdomen,  and  the 
legs  flexed  towards  the  thighs.  In  this  position  the  two  axes  are  brought 
more  nearly  into  one  line  than  in  any  other,  and  the  head  is  directed  more 
completely  over  the  centre  of  the  brim.  It  is  equally  necessary,  or  even 
more  so,  to  keep  strictly  in  mind  the  relation  that  the  two  axes  of  the 
brim  and  outlet  bear  to  each  other ; and  this  especially  while  performing 
any  obstetrical  operation.  When  using  the  forceps,  for  example,  should 
we  neglect  this  most  essential  precaution,  we  shall  not  only,  in  all  proba- 
bility, be  foiled  in  accomplishing  delivery,  but  we  shall  run  the  almost 
certain  risk  of  inflicting  irreparable  injury  on  the  woman. 

Joints  and  Ligaments  of  the  Pelvis . — Besides  the  joints  proper  to  the 
coxyx,  the  pelvis  possesses  three  others  already  mentioned ; — one  uniting 
the  pubic  bones  in  front,  the  symphysis  pubis — and  one  on  each  side  of 
the  sacrum,  connecting  that  bone  with  the  ilia,  the  sacro-iliac  symphyses. 
These  articulations  are  bound  together  by  exceedingly  strong  unyielding 
ligaments,  as  well  within  as  externally.  The  ligamentous  expansions  on 
the  interior  of  the  pelvis  are  much  thinner  than  those  on  the  outside ; and 
although  they  assist  greatly  in  strengthening  the  connexions  of  the  bones, 
they  occupy  but  little  space,  and  consequently  do  not  encroach,  in  any 
considerable  degree,  upon  the  room  required  by  the  head  in  labour. 

In  addition  to  the  ligaments  belonging  to  the  joints,  there  are  the  obtu- 
rator ligaments,  filling  up  almost  the  whole  of  the  obturator  foramina ; and 
the  sacro-sciatic , or  sacro-ischiatic  ligaments,  of  much  interest  to  the  ob- 
stetrical student.  These  run  in  two  fasciculi  on  each  side,  the  lower  ob- 
liquely upwards,  and  backwards  from  the  base  of  the  tuber  ischii  to  the 
side  of  the  sacrum,  and  the  other  horizontally  backwards  from  the  spi- 
nous process  of  the  ischium  to  the  lower  part  of  the  sacrum  and  the  coxyx ; 
and  both  are  widely  spread  on  the  outside  of  the  last-named  bones  like  a 
fan,  Plate  IV.  figs.  13  and  14.  They  tend,  in  a great  degree,  to  render 
the  outlet  of  the  pelvis  firm,  by  connecting  together  the  sacrum  and  the 
ischia.  They  partake  of  the  relaxation  which  the  soft  structures  undergo 
in  labour,  and  a preternatural  rigidity  existing  in  their  fibres  is  occasion- 
ally a cause  of  retardation  in  the  process. 

Separation  of  the  Joints  of  the  Pelvis  during  Labour. — It  was  for  many 
centuries  the  prevalent  opinion  that  the  bones  of  the  pelvis  always  sepa- 
rated, or  were  disposed  to  separate,  if  occasion  required  it,  during  partu- 
rition, especially  at  the  symphysis  pubis,  and  thus  allowed  the  pelvic 
dimensions  to  be  increased  in  every  direction.  This  idea  was  rendered 
more  probable  by  analogy ; for  it  is  said  that  in  some  animals,  as  the  cow, 


28 


DIFFERENCE  IN  FORM  BETWEEN 


the  bones  are  absolutely  disunited  to  some  extent ; and  that  the  sinking  of 
the  sacrum,  occasioned  by  its  own  weight  and  by  the  softened  condition 
of  the  ligaments,  together  with  a difficulty  in  progressive  motion,  is  an 
indication  of  the  near  approach  of  parturition.  Such  a separation  may 
possibly  take  place  in  the  lower  animals,  but  it  is  certainly  not  usually  the 
case  in  the  human  subject.  The  joints  are  liable,  indeed,  to  inflammation; 
and  pus  being  secreted  between  the  bones  may  occasion  disunion — a dis- 
ease attended  with  high  constitutional  excitement,  and  no  small  danger. 
Sometimes,  also,  an  actual  separation  of  the  bones  takes  place,  both 
during  pregnancy  and  after  labour,  from  simple  relaxation  of  the  liga- 
ments, which  state  gives  rise  to  pain  in  the  part  deranged,  and  an  inability 
to  walk  or  stand  without  artificial  support.  This  affection,  though  not 
attended  with  so  much  suffering  or  hazard  as  acute  inflammation,  is  never- 
theless of  a very  distressing  character,  and  very  difficult  of  cure ; com- 
monly confining  the  patient  to  bed  or  the  sofa  for  many  months.  But  it 
would  be  travelling  too  far  out  of  the  limits  of  this  publication  to  enter 
minutely  into  the  history  of  these  diseases ; and  it  is  sufficient  for  our  pre- 
sent purpose  to  know  that  in  the  great  majority  of  cases,  there  is  no  sen- 
sible relaxation  of  the  pubic  or  sacro-iliac  ligaments ; that  in  others  a soft- 
ening does  occur  in  various  degrees,  and  that  when  that  change  reaches 
such  a point  as  to  be  attended  with  pain  or  inconvenience,  it  must  be  con- 
sidered as  morbid. 

Difference  in  Form  between  the  Male  and  Female  Pelvis  and  Skeleton. — 
On  comparing  the  male,  Plate  III.  fig.  9,  and  female  pelvis,  fig.  10,  to- 
gether, we  cannot  but  remark  a striking  difference  in  the  general  appear- 
ance and  particular  proportions  of  this  organ  in  the  two  sexes.  We  ob- 
serve that  the  pelvis  of  the  female  is  altogether  larger  and  more  delicately 
shaped  than  that  of  the  male ; that  the  alee  of  the  ilia  spread  themselves 
widely  in  the  lateral  direction ; while  the  same  parts  in  the  male  rise  more 
perpendicularly  upwards.  The  brim  is  differently  shaped ; the  long 
diameter  in  the  female  being  from  side  to  side ; in  the  male  from  before 
backwards.  The  cavity  is  considerably  smaller  in  the  male,  deeper,  and 
more  of  a funnel  shape,  the  sacrum  being  much  straighter,  Plate  IV. 
fig.  13,  and  the  tuberosities  of  the  ischia  inclining  closer  together.  The 
outlet  is  also  far  less  capacious ; and  this  arises  principally  from  the  ap- 
proximation of  the  ischia,  which  seldom  are  more  than  three  inches  dis- 
tant at  the  widest  diameter.  The  arch  of  the  pubes  is  formed  more  an- 
gularly than  in  the  female,  in  whom  this  part  approaches  nearer  to  the 
perfection  of  an  arch,  Plate  III.  figs.  9 and  10.  In  the  female,  too,  the 
rami  of  the  ischia  and  pubes  are  smoother  on  their  inner  surface,  and 
their  anterior  edge  is  turned  more  outwards.  This  disposition  of  the  rami 


THE  MALE  AND  FEMALE  PELVIS. 


29 


helps  to  enlarge  the  outlet,  and  gives  an  elegance  to  the  whole  organ  that 
is  wanting  in  the  pelvis  of  the  stronger  sex. 

All  the  bones  of  the  male  skeleton  are  firmer  and  heavier  than  they  are 
in  the  female,  and  more  powerfully  marked  by  those  irregularities  which 
indicate  muscular  attachments.  The  thoracic  cavity  is  comparatively 
larger,  and  the  acromia  are  at  a greater  distance  from  each  other.  A 
line  drawn  from  the  head  of  the  humerus,  perpendicularly  downwards, 
would  fall  to  the  ground  altogether  clear  of  the  pelvis ; but  in  a well- 
articulated  female  skeleton,  the  same  line  would  rest  within  the  ala  of  the 
ilium.  It  is  this  difference  that  gives  the  broad  shoulders  to  the  male,  and 
the  swelling  hips  to  the  female,  and  occasions  the  principal  distinction  in 
the  outline  of  the  form  between  the  sexes,  Plate  I.  figs.  1 and  2.* 

* These  figures  are  sketched  from  Maygrier’s  work.  It  might  perhaps  be  thought  more 
desirable  in  some  respects,  if  the  characteristic  difference  between  the  male  and  female  out- 
line had  been  shown  by  drawings  of  the  skeletons ; but  as  the  contrast  by  such  a mode  of 
illustration  would  not  have  been  so  strongly  marked,  I have  preferred  giving  an  etching  of 
the  full  form.  The  elliptical  lines  will  direct  the  eye  to  the  principal  points  worthy  of 
attention. 


11 IV. 


ft 

*r 


9 


ft 


Sindnxr  * iPluLl 


LIBRARY 

OF  THE 

UNIVERSITY  OF  ILLINOIS 


v 


OF  THE  FGETAL  HEAD. 


Plate  V. 


Shape  and  Dimensions  of  the  Foetal  Head  at  Birth. — As  both  the  brim 
and  outlet  of  the  pelvis  present  a form  inclining  to  oval,  so  the  foetal  skull 
is  of  a similar  shape.  It  is,  indeed,  more  perfectly  oval;  the  long 
diameter,  when  the  face  is  put  out  of  calculation,  being  from  the  occiput 
to  the  forehead,  Plate  V.  fig.  16,  (a.  h. ;)  the  short  from  the  tuberosity  of 
one  parietal  bone,  to  that  of  the  other,  Plate  V.  fig.  18,  {a.  h.) 

In  extent,  at  birth,  the  long  diameter  measures  four  inches  and  a half, 
and  the  short  three  and  a half;  the  circumference,  drawn  in  a line  over 
the  ridge  of  the  occipital  bone,  above  the  ears,  and  traversing  the  most 
prominent  part  of  the  frontal  bones,  is  nearly  fourteen  inches.  It  must 
not  be  supposed  that  these  measurements  are  exact  or  universal,  any  more 
than  that  the  admeasurements  given  of  the  pelvis  are  always  the  same ; 
but  as  we  take  a fancied  standard  pelvis  as  our  guide,  in  the  same 
manner  we  choose  a standard  head — such  a one,  perhaps,  as  is  most 
commonly  met  with.  I shall  only  mention  one  other  diameter  of  the 
foetal  head,  because,  by  multiplying  such  observations  unnecessarily,  the 
mind  is  distracted  and  the  memory  clogged,  viz.  that  from  the  vertex  to 
the  chin,  which  is  five  inches  and  a half,  capable,  however,  of  elongation 
under  labour,  from  the  head  being  compressed  laterally,  to  the  extent  of 
six  and  a half  or  seven  inches.*  The  long  diameter  of  the  cranium,  from 

* It  is  generally  remarked  that  the  skull  of  the  male  child  is  a little  larger  in  all  its  dia- 
meters than  that  of  the  female.  Of  sixty  male,  and  sixty  female  children,  born  at  full  time, 
Dr.  Jos.  Clarke  found  the  average  circumference  of  the  head  to  be  14  inches  in  the  males; 
13|ths  in  the  females.  The  arch,  from  ear  to  ear  over  the  crown  was  7ith  in  the  males, 
7ph  in  the  females.  Of  the  120  examined,  only  six  exceeded  1 4%  inches  round,  and  all 
these  were  males. — Letter  to  Dr.  Price. 


32 


FCETAL  SKULL. 


the  forehead  to  the  occiput,  being  four  inches  and  a half,  and  the  short 
diameter  three  and  a half,  it  follows  that  when  the  head  is  properly- 
adapted  to  the  pelvis,  a clear  superabundant  space  of  at  least  half  an  inch 
is  left  between  the  cranial  and  pelvic  bones,  both  in  the  lateral  and  con- 
jugate diameters,  which  is  generally  quite  sufficient  for  the  easy  passage 
of  the  head. 

Anatomical  Peculiarities  of  the  Foetal  Skull. — The  general  anatomical 
character,  as  well  as  the  form  and  size  of  the  skull,  deserve  our  attention. 
It  may  be  seen  that  the  bones  are  not  dove-tailed  into  each  other  as  in 
the  adult,  but  are  separated  to  some  extent  by  intervening  lines  and  spaces 
of  membranous  formation.  The  lines  are  termed  sutures , from  the  Latin 
word  suo , to  sew;  the  spaces ,fontanelles,  after  the  French;  because  it 
used  to  be  supposed  that  a moisture  distilled  from  the  brain  through  these 
unossified  apertures.  The  fontanelle  has  also  been  called  bregma,  from 
j3 pex*>,  to  moisten — the  name  having  originated  in  the  same  idea. 

The  bones  in  the  child’s  skull  requiring  our  consideration  obstetrically  , 
are  but  few,  the  two  'parietal  bones  of  a square  shape,  which  give  the 
principal  protection  to  the  brain  laterally,  Plate  V.  fig.  18,  {a.  h.i)  the 
frontal  bone  anteriorly,  Plate  V.  fig.  15 — or  rather  the  frontal  bones, 
because,  in  the  foetus  there  are  two, — and  the  occipital  posteriorly,  Plate 
Y.  fig.  19.  The  parietal  bones  are  separated  from  the  frontal,  or  con- 
nected with  them,  by  a suture  called  caronal,  Plate  Y.  fig.  17,  and  Plate 
V.  figs.  15  and  16,  which  runs  from  near  the  external  angle  of  one  eye 
to  the  same  point  on  the  opposite  side  of  the  head,  bounding  the  forehead 
superiorly.  It  is  called  caronal,  because  the  ancients  used  to  wear  their 
caronce  or  garlands  on  that  part  of  the  head  upon  festive  occasions.  The 
parietal  bones  are  separated  from  the  occipital  by  a suture,  termed  lam- 
doidal,  from  its  resemblance  to  the  Greek  letter.  A,  Plate  Y.  figs.  16  and 
19.  The  two  parietal  bones  are  separated  from  each  other  by  the  sagittal 
suture,  Plate  Y.  fig.  18,  which  runs  longitudinally  along  the  centre  of  the 
upper  part  of  the  head,  so  called  because  it  was  fancifully  supposed  to  be 
situated  between  the  lamdoidal  and  coronal  sutures,  os  an  arrow  is  placed 
in  a strung  bow.  The  two  frontal  bones  are  separated  by  the  frontal 
suture,  Plate  Y.  fig.  15,  which  runs  directly  upwards  from  the  root  of  the 
nose.  The  remaining  sutures  of  the  head  are  out  of  the  way  of  our 
obstetrical  observation,  and  a description  of  them  would  therefore  be 
useless. 

The  two  fontanelles  are  placed,  one  at  each  extremity  of  the  sagittal 
suture ; and  they  are  named,  according  to  their  situation,  anterior,  Plate 
Y.  figs.  15, 17  and  18,  (c,)  and  posterior,  Plate  Y.  figs.  18  and  19  ( d .)  The 
anterior  fontanelle  is  by  far  the  larger,  quadrangular  or  diamond-shaped : it 
is  sufficiently  extensive  to  take  in  the  whole  extremity  of  the  finger,  and 


F(ETAL  SKULL. 


33 


can  scarcely  be  covered  by  it.  The  posterior  is  small  and  triangular. 
The  peculiar  form  of  the  anterior  fontanelle  is  caused  by  the  junction  of 
the  corners  of  four  bones  rounded  off,  the  two  parietal  and  the  two 
frontal ; the  posterior  is  formed  as  a triangle  by  the  union  of  three  bones, 
the  superior  posterior  angles  of  the  two  parietal  bones,  and  the  upper 
angle  of  the  occipital  bone. 

Necessity  for  Learning  the  Situation  of  the  Fontanelles  and  Sutures. — 
An  accurate  knowledge  of  the  form  and  situation  of  these  fontanelles  is 
of  absolute  necessity  for  the  successful  practice  of  the  obstetric  art ; for 
by  them  we  detect  the  position  of  the  foetal  head  in  the  the  early  stage  of 
labour.  The  vertex  is  generally  the  presenting  part,  or  that  which  offers 
itself  most  readily  to  the  finger  on  examination.*  This  may  be  regarded, 
then,  as  the  most  natural  presentation ; the  head,  when  placed  with  the 
vertex  downwards,  will  pass  through  an  aperture  of  much  less  dimensions 
than  it  would  do,  were  any  other  part  descending  first.  In  Plate  V.  fig.  19, 
a view  of  the  vertex  is  given,  and  two  somewhat  oval  lines  are  traced 
surrounding  it.  One  of  these  ovals  is  an  inch,  in  its  long  diameter, 
greater  than  the  other.  The  smaller  shows  the  quantity  of  space  requisite 
for  the  transit  of  the  head,  when  the  vertex  offers  itself,  four  inches  and 
a quarter  by  three  inches  and  a half  in  diameter ; the  larger  indicates 
that  necessary  for  the  same  head,  when  the  brow  or  anterior  fontanelle 
presents,  being  five  inches  and  a quarter  by  three  and  a half;  and  by 
contrasting  the  two  together,  the  student  will  be  able  to  form  a correct 
idea  of  the  advantages  appertaining  to  the  presentation  of  the  vertex. 

If,  then,  in  an  obstetrical  examination  we  distinguish  the  posterior 
fontanelle  readily,  we  know  that  the  vertex  is  presenting ; we  may 
presume  that  the  foetus  is  placed  in  the  most  favourable  position, 
and  we  may  augur,  cceteris  paribus , an  easy  termination  of  labour. 
If,  on  the  contrary,  we  at  once  distinctly  feel  the  large  open,  dia- 
mond-shaped space,  we  are  satisfied  that  the  brow  or  forehead  is 
downward.  We  know  that  this  is  an  unfortunate  situation  of  the  head, 
because  so  much  more  room  will  be  occupied  in  its  transit ; and  we  are, 
therefore,  prepared  to  expect  that  the  case  will  be  lingering ; we  may 
even  feel  justified  in  attempting  to  place  the  head  in  a better  direction. 

Nor  is  it  of  less  moment  that  the  sutures  should  be  attended  to.  The 
cranium  ordinarily  enters  the  pelvis  with  the  face  looking  to  one  sacro- 
iliac symphysis.  Should  we  then  detect  the  sagittal  suture  running 
diagonally  across  the  pelvis,  we  infer  that  the  long  diameter  of  the  head 
is  in  the  direction  of  one  of  the  long  diameters  of  the  pelvis,  and  so  far  all 

* The  term  vertex  is  applied  to  that  part  of  the  head  from  whence  the  hair  diverges  as 
from  a centre.  It  is  generally  described  as  being  directly  over,  but  in  fact,  it  is  placed  rather 
before  the  posterior  fontanelle, 


34 


F CE  T A L SKULL. 


is  well ; but  if  it  crosses  the  brim  in  a direct  line  antero-posteriorly,  the 
head  is  placed  with  its  long  diameter  in  the  short  diameter  of  the  pelvic 
entrance;  and  we  know  that  it  cannot  pass  into  the  cavity  while  so 
situated,  provided  the  skull  and  pelvis  are  both  of  normal  form  and  size. 
Having  obtained  this  information,  we  regulate  by  it  both  our  prognosis 
and  our  practice. 

Advantages  of  the  peculiar  structure  of  the  Foetal  Head. — Many  advan- 
tages attend  on  this  peculiar  conformation  of  the  foetal  skull.  On  the  one 
hand,  the  bones  being  separated  by  intervening  lines  and  spaces,  permit  a 
more  uniform  growth  and  development  to  the  tender  brain  than  could 
take  place  had  the  cranium  been  originally  composed  of  one  solid  bony 
case ; and  on  the  other  hand,  (which  indeed  most  interests  us  as  obstetri- 
cians,) a certain  degree  of  compression  is  allowed  under  labour ; the  edge 
of  each  bone  has  an  opportunity  given  to  it  to  ride  a little  over  its  neigh- 
bour; the  capacity  of  the  child’s  head  is  thus  diminished,  and  it  is 
capable  of  being  propelled  through  a smaller  space  than  if  it  had  been 
fashioned  of  one  continuous  piece.  This  power  of  diminution  is  greatest 
in  the  lateral  diameter;  and  a full-grown  foetal  head  may  be  lessened 
from  side  to  side,  without  endangering  the  child’s  life,  one-seventh  of  its 
own  extent,  or  from  three  inches  and  a half  to  three  inches.  This  over- 
lapping of  the  bones  in  labour  is  of  common,  nay,  almost  universal 
occurrence;  and  the  compressibility  of  the  head  should  teach  us  to 
hesitate,  and  consider  well  the  bearings  of  the  case,  before  we  take  in 
hand  an  obstetric  instrument,  especially  such  a one  as  cannot  be  used 
without  the  sacrifice  of  the  child’s  life ; for  it  is  constantly  observed  in 
practice,  that  a fortunate  and  natural  termination  has  occurred  in  cases 
where,  a few  hours  before,  it  was  believed  impossible  that  the  child  could 
be  born  without  instrumental  interference. 

Some  practitioners  suppose  that  another  good  effect  is  produced  by  the 
compressibility  of  the  foetal  cranium.  It  is  thought  that,  in  the  passage 
of  the  head  through  the  pelvis,  the  child  is  thrown  into  a state  of  sleep  or 
torpor,  during  which  its  limbs  are  for  the  time  paralyzed,  and  it  is  conse- 
quently prevented  injuring  the  maternal  structures  by  any  violent  move- 
ment or  struggle.  I am  inclined  myself  to  subscribe  to  this  opinion. 

Expulsion  of  the  Head  vertically. — The  student  being  now  acquainted 
with  the  size  and  figure  of  the  female  pelvis,  and  the  dimensions  of  the 
child’s  head,  is  prepared  to  understand  the  mechanism  of  its  passage  in 
cases  of  ordinary  labour.  It  enters  the  brim  with  the  vertex  as  the  most 
dependent  part,  with  the  face  to  one  ilium  and  the  occiput  to  the  other, 
or  more  commonly  with  the  face  looking  towards  one  sacro-iliac  sym- 
physis, and  the  occiput  behind  the  groin  on  the  opposite  side  of  the  body. 
Descending  in  this  direction,  it  takes  full  possession  of  the  cavity,  and  the 


FCETAL  SKULL.  35 

forehead  and  occiput  impinge  respectively  on  the  inner  surfaces  of  the  tubero- 
sities of  each  ischium.  Since,  however,  in  this  position,  its  long  diameter 
is  opposed  to  the  short  diameter  of  the  outlet, — since  the  tuberosities  of 
the  ischia  are  unyielding, — and  since  the  long  diameter  of  the  head  exceeds 
the  short  diameter  of  the  outlet  by  half  an  inch, — it  is  evident  that  a change 
in  its  relative  situation  must  be  made  before  it  can  be  expelled.  This  altera- 
tion is  effected  by  a slight  rotation  of  the  cranium  ; the  face  is  thrown  into 
the  hollow  of  the  sacrum,  the  occiput  peeps  up  under  the  arch  of  the 
pubes,  and  the  head  eventually  escapes  with  the  face  sweeping  the  sacrum, 
coxyx,  and  perineum.  This  turn  is  produced  by  mechanical  causes,  and 
depends  on  the  resistance  which  the  peculiar  construction  of  the  pelvic 
bones  opposes  to  the  propelling  efforts  exerted  by  the  uterus : — the  inner 
surfaces  of  the  ischia,  somewhat  approaching  each  other  as  they  descend, 
together  with  the  spinous  processes  of  the  same  bones,  afford  an  inclined 
plane  along  which  the  head  is  directed;  the  hollow  of  the  sacrum  offers 
an  unoccupied  cavity,  into  which  the  face  is  received,  and  the  arch  of  the 
pubes  a wide-spreading  sinuosity,  through  which  the  occiput  insinuates 
itself.  The  foetus,  indeed,  does  not  assist  in  the  least  degree,  by  any  volun- 
tary action  of  its  own,  to  perfect  this  change ; it  is  entirely  to  be  explained 
on  mechanical  principles ; and  the  opinion  of  the  ancient  physicians,  that 
the  child,  by  its  innate  powers,  assists  in  liberating  itself  from  its  impri- 
sonment, is  perfectly  fallacious. 


V 


1 


■ 


' 


’ 

♦ 


4 * 


f'iy.  16. 


Ipi^, 

v5'- 


t’TUf.lD. 


ft ft-  7j. 


J 'in  clr*  >r's  Jj  vth  ‘ 


OF  DEFORMED  PELVES. 


Plates  VI.,  VII.,  VIII. 

Fortunate  would  it  be  for  child-bearing  women  if  they  each  possessed 
a pelvis  of  the  figure  and  dimensions  already  given  as  the  standard.  Such, 
however,  is  by  no  means  the  case ; and  this  organ  is  subject  to  great  varie- 
ties, as  well  in  form  as  size.  It  would,  indeed,  be  difficult  to  select  from 
all  the  preserved  specimens  in  existence,  any  two  which  exactly  resemble 
each  other — agreeing  minutely  in  shape,  dimensions,  and  weight.  Many 
are  found  to  be  much  above  the  ordinary  volume,  and  numbers,  on  the 
other  hand,  greatly  below  it. 

The  want  of  due  capacity  sometimes  originates  in  natural  formation; 
thus  a woman  of  short  stature,  although  of  tolerable  symmetry,  might 
be  expected  to  possess  a diminutive  pelvis ; but  this  is  far  from  being  a 
universal,  or  even  general  remark.  Again,  the  re-union  of  the  bones  after 
fractures  will  commonly  occasion  both  distortion  and  contraction  of  space; 
but  when  there  exists  a deficiency  of  room  to  any  great  extent,  the  irre- 
gularity is  mostly  dependent  on  disease  of  the  bones  themselves. 

If  we  look  at  the  head  of  the  child,  and  the  cavity  through  which  it  has 
to  traverse,  in  a mechanical  point  of  view,  (which  we  must  do  before  we 
can  arrive  at  a correct  knowledge  of  the  process  of  parturition,  even  in 
the  simplest  and  most  easy  state,)  we  shall  immediately  perceive  that  size, 
as  regards  the  head  and  the  pelvis,  is  entirely  a relative  term  ; and  that  a 
pelvis  preternaturally  small,  or  a head  unusually  large,  will  each  in  practice 
occasion  difficulty  in  the  same  degree  as  they  deviate  from  the  standard 
dimensions;  so  that  it  matters  little  whether  the  disproportion  be  the 
consequence  of  diseased  action  or  any  other  cause ; provided  it  exists, 


38 


DEFORMED  FELVES. 


to  a certain  extent,  it  must  necessarily  be  productive  of  a protracted 
struggle. 

There  are  two  diseases  particularly  through  which  the  pelvis  suffers 
considerable  deterioration  in  size,  rachitis  or  riclzets , a disorder  of  child- 
hood,—and  mollities  ossium  or  malacosteon,  one  of  adult  age.  In  both 
these  affections  there  is  a want  of  due  solidity  in  the  osseous  system  through- 
out the  whole  body.  The  animal  matter  entering  into  the  composition  of 
the  skeleton  being  in  great  excess,  and  the  earthy  matter  in  proportionate 
deficiency,  the  bones  yield  like  softened  wax ; the  regularity  and  beauty  of 
the  pelvic  form,  as  well  as  of  other  bony  cavities,  is  destroyed,  and  the 
miserable  specimens  of  distortion  portrayed  in  Plates  VI.,  VII.,  and  VIII., 
are  the  result. 

Deformity  may  be  partial  or  general, — partial  when  either  of  the  parts, 
the  brim,  cavity,  or  outlet,  is  simply  the  subject  of  derangement, — general, 
when  all  these  are  more  or  less  involved.  If  the  vicious  formation  be  con- 
fined to  the  brim,  the  diminution  in  size  is  almost  always  produced  by  the 
promontory  of  the  sacrum  jutting  too  far  forwards,  and  by  this  means  con- 
tracting the  conjugate  diameter ; if  to  the  cavity,  by  the  sacrum  being  too 
straight,  so  that  the  bone  does  not  possess  its  due  curvature ; if  to  the  out- 
let, by  the  tuberosities  of  the  ischia  approaching  too  near  each  other ; or 
by  the  spinous  processes  of  the  same  bones  being  too  long,  and  directed 
too  much  inwards ; or  again,  by  the  joints  of  the  coxyx  having  become 
anchelosed,  and  having  thus  lost  their  mobility.  Of  these  irregularities 
the  most  frequent  is  that  met  with  at  the  brim  ; the  most  rare,  an  undue 
straitness  of  the  sacrum. 

It  is  easy  to  account  for  the  frequency  of  contraction  at  the  brim, 
because  the  base  of  the  sacrum  supports  the  whole  weight  of  the  trunk, 
head,  and  upper  extremities ; and  as  the  sacral  promontory  partakes  of  the 
curve  forward  proper  to  the  lumbar  vertebrae,  it  is  reasonable  to  suppose, 
that  if  any  degree  of  softness  exists  in  the  bones,  they  will  bow  at  this 
point  first,  being  unable  to  resist  the  superincumbent  pressure.  Giving 
way  in  this  manner,  the  lowest  lumbar  vertebra,  and  the  upper  part  of  the 
sacrum,  will  be  thrown  inwards,  so  as  to  dip  over  the  entrance  to  the 
pelvic  cavity. 

If  we  rest  a perfectly  straight  wire  perpendicularly  on  a table,  and  place 
a weight  upon  its  top  greater  than  it  can  sustain,  it  will  bend,  but  at  what 
part  we  cannot  tell.  If,  however,  we  make  the  least  elbow  in  it  before 
we  try  the  experiment,  we  shall  find  that  it  will  yield  there  rather  than  in 
any  other  part.  This  is  exactly  analogous  to  the  condition  of  the  sacral 
promontory  and  last  bone  of  the  loins. 

In  Plate  VI.,  figs.  20  and  21,  two  specimens  are  given  of  this  kind  of 
deformity  at  the  brim.  The  original  from  which  figure  20  was  engraved. 


S vinTavrs  L vthrFhJ  " 


DEFORMED  PELVES. 


39 


is  preserved  in  the  London  Hospital  Museum : it  measures  five  inches  in 
the  lateral  diameter ; two  inches  and  three-quarters  in  the  sacro-pubic ; 
and  the  same  from  each  side  of  the  sacrum  to  the  ramus  of  the  pubes. 
This  is  just  below  the  minimum  space  through  which  a full-grown  foetal 
head  could  pass  entire ; but  the  ischial  tuberosities  are  four  inches  and 
three-eighths  apart,  the  distance  between  them  being  full  a quarter 
of  an  inch  more  than  in  a healthy  pelvis,  so  that  the  outlet  is  wider 
than  natural;  and  as  the  sacral  curve  is  well  proportioned,  if  the  head 
once  gained  possession  of  the  cavity,  it  would  speedily,  and  with  little 
farther  exertion,  be  expelled. 

Figure  21,  represents  the  pelvis  of  a woman  whom  I delivered  in 
a state  of  great  exhaustion,  under  a primary  labour  by  craniotomy ; and 
is  considerably  contracted  in  all  its  dimensions,  more  especially  at  the 
brim.  The  diameter,  from  the  centre  of  the  prominence  of  the  sacrum  to 
the  symphysis  pubis,  is  only  two  inches  and  a quarter;  the  iliac  diameter 
four  inches  and  three-quarters ; on  the  right  side  of  the  promontory  of  the 
sacrum  to  the  pubic  ramus,  the  space  is  two  inches  and  a half ; on  the 
left  side  two  inches  and  a quarter.  The  cavity  is  much  below  the  natural 
size,  the  depth  posteriorly  being  not  more  than  four  inches;  the  outlet  also 
is  considerably  diminished,  as  well  by  the  width  between  the  ischia  mea- 
suring only  three  inches  and  a quarter,  as  by  the  elongation  of  the  spinous 
processes  of  those  bones. 

In  most  cases  of  partial  deformity  at  the  brim,  the  lateral  diameter  is 
increased  in  size  nearly  in  the  same  proportion  as  the  conjugate  is  dimi- 
nished ; but  however  much  the  width  from  ilium  to  ilium  may  exceed  the 
ordinary  dimensions,  the  increased  space  thus  obtained  will  in  no  degree 
make  amends  for  the  diminution  from  the  sacrum  to  the  pubes ; because 
it  is  necessary  that  there  should  not  exist  less  than  a certain  quantity  of 
available  room  in  every  direction  to  permit  the  child’s  transit. 

When  the  deformity  is  complete  by  involving  the  cavity  and  outlet  as 
well  as  the  brim,  it  may  be  of  two  kinds — angular,  as  shown  in  Plates  VI., 
fig.  22,  and  VII.,  fig.  23, — or  elliptical,  as  in  Plate  VIII.  figs.  26,  27.  In  the 
angular  distortion  the  promontory  of  the  sacrum  is  thrown  forwards ; the  tu- 
berosities of  the  ischia  closely  approach  each  other ; and  the  symphysis  pu- 
bis projects  outwards.  The  pelvis  bears  the  appearance  as  though  it  were 
formed  of  ductile  matter,  and  the  pubic  bones  at  each  side  of  their  junc- 
tion had  been  squeezed  forcibly  together.  In  the  elliptical,  the  sacral  pro- 
minence projects  forwards ; the  tuberosities  of  the  ischia  are  separated  to 
a much  wider  extent  than  is  usual ; and  the  bones  at  the  symphysis  pubis 
are  flattened,  being  forced  back  towards  the  sacrum  ; thus  a greater  lateral 
diameter  is  given  both  to  the  brim  and  the  outlet. 

It  is  generally  believed  that  the  elliptical  species  of  distortion,  Plate 


40 


DEFORMED  PELVES. 


VIII.,  is  invariably  the  consequence  of  rickets;  while  the  angular,  Plates 
VI.,  fig.  22,  and  VII.,  fig.  23,  is  as  invariably  produced  by  mollities 
ossium;  and  Dr.  Hull,  in  his  second  letter  to  Simmonds,  has,  by  a very 
ingenious  chain  of  reasoning,  endeavoured  to  substantiate  this  hypo- 
thesis. I am  far  from  subscribing  to  the  universal  truth  of  this  doctrine ; 
but  am  inclined  to  think  that  both  these  diseases  may  occasion  each 
variety. 

To  render  the  subject  more  easily  understood,  I shall  divide  pelves  into 
four  gradations,  and  I shall  classify  them  according  to  their  form  at  the 
brim,  since  that  is  the  part  most  usually,  as  well  as  most  severely,  dis- 
torted. The  first  embraces  the  standard  pelvis— five  inches  and  a quarter 
in  the  lateral  diameter,  by  four  in  the  conjugate,  and  all  above  that  mea- 
surement, through  which  a mature  foetus  will  escape  with  facility. 

The  second  class  includes  those  lower  than  the  standard,  but  suffi- 
ciently large  to  permit  the  child’s  passing  alive,  being  either  expelled  by  the 
unaided  efforts  of  nature,  or  extracted  by  instruments  which  are  perfectly 
compatible  as  well  with  its  preservation  as  with  the  safety  and  integrity 
of  the  woman’s  structures.  A live  birth  may  be  accomplished  through  a 
pelvis  which  possesses  a clear  available  space  of  three  inches  in  the 
conjugate,  by  four  in  the  lateral  diameter.  Some  practitioners  have 
thought  that  a pelvis  measuring  only  two  inches  and  three-quarters  in 
the  conjugate  diameter  would  allow  of  the  head  passing  whole,  pro- 
vided there  were  sufficient  room  laterally.  My  own  conviction,  derived 
from  clinical  observation,  is,  that  the  dimensions  I have  just  mentioned 
are  the  smallest  which  will  grant  a passage  to  a full-grown  unmutilated 
foetus. 

In  the  third  class  is  comprehended  every  pelvis  of  such  a size  as  would 
admit  of  a well-educated  practitioner  extracting  a foetus  through  it,  after 
the  bulk  has  been  diminished  by  cutting  instruments  to  the  smallest  pos- 
sible compass.  Although  most  obstetricians  agree  that  three  inches  by 
four  is  about  the  least  space  through  which  a full  sized  foetal  head  will 
pass  entire,  there  is  an  extraordinary  difference  of  opinion  in  regard  to 
this  other  question ; some  thinking  that  little  more  than  an  inch  in  the  con- 
jugate diameter  will  suffice;  others,  that  very  considerably  more  is  required. 
This  discrepancy  may,  perhaps,  in  some  measure,  be  accounted  for  by  the 
superior  tact  which  long  and  constant  practice  in  obstetrical  operations 
gives ; for  it  is  reasonable  to  suppose  that  a person  unaccustomed  to  these 
duties  will  not  succeed  so  well  as  one  to  whom  they  occur  frequently.  It 
is  left  to  me,  therefore,  to  form  a scale  of  my  own  as  the  lowest  limit 
through  which  a child  can  be  drawn  after  mutilation ; and  I am  quite 
convinced  that  unless  there  be  at  the  brim  one  inch  and  three  eighths  in 
the  conjugate,  by  three  and  a half  in  the  iliac,  or  one  inch  and  a half  in 


■Fig-  £3. 


PL  VII. 


* 


LIBRARY 
Or  1HE 

lNIVLRSJTY  OF  iimnois 


DEFORMED  PELVES. 


41 


the  conjugate,  by  three  in  the  iliac,  it  would  be  useless  to  attempt  delivery 
per  vias  naturales;  but  it  will  very  rarely  indeed  be  found  that  the  lateral 
diameter  at  the  brim  does  not  exceed  three  inches.  One  point,  however, 
should  be  borne  in  mind  in  making  this  computation,  that  if  the  brim  alone 
be  distorted,  a much  less  amount  of  room  is  requisite  for  extraction  than 
in  cases  where  the  cavity  and  outlet  are  proportionally  lessened  in  their 
dimensions. 

In  the  last  class  or  gradation  are  to  be  included  all  pelves  below  the 
minimum  space  just  mentioned ; through  which  it  is  impossible  for  the 
most  skilful  and  experienced  operator  to  extract  a foetus,  even  after  the 
brain  has  been  evacuated,  and  the  body  diminished  to  the  utmost  extent 
that  art  can  accomplish.  In  cases  of  such  extreme  deformity,  no  means 
remain  of  rescuing  the  woman  from  death  through  exhaustion  but  to  open 
the  abdomen,  cut  into  the  uterine  cavity,  and  extract  the  foetus  by  the 
artificial  aperture ; an  operation  horrible  to  contemplate,  and  which  in  the 
British  islands  has,  with  three  exceptions,  proved  universally  fatal  to  the 
mother. 

The  subjects  for  the  plates  have  been  selected  with  the  view  of  illus- 
trating the  different  positions  laid  down.  The  measurements  of  the  two 
distorted  pelves  in  Plate  VIII.,  have  been  already  given : through  the  upper, 
fig.  26,  some  obstetricians  think  it  possible  that  a full-grown  and  commonly- 
ossified  foetal  head  might  pass  entire  with  great  exertion,  though  I should 
much  doubt  it ; through  the  lower,  fig.  27,  no  mature  foetus  of  ordinary 
weight  could  be  born  alive. 

In  Plates  VI.  fig.  22,  and  VII.  fig.  23,  are  given  two  specimens  of  the 
angular  distortion.  The  brim  of  fig.  22,  in  its  long  diameter,  measures 
four  inches  and  a half ; the  greatest  available  space  between  the  pubes  and 
sacral  promontory  is  one  inch  and  five-eighths ; on  the  left  side  of  the  pro- 
montory there  are  two  and  three-eighths ; and  on  the  right  side  two  inches 
and  a half.  The  tuberosities  of  the  ischia  at  their  nearest  points  approach 
each  other  to  within  an  inch  and  three-fourths ; and  the  distance  between 
the  tip  of  the  coxyx  and  the  under  edge  of  the  symphysis  pubis  is  four 
inches  and  a half.  It  would  be  perfectly  possible  to  deliver  the  patient 
who  possessed  this  pelvis,  by  the  operation  of  craniotomy. 

Fig.  23,  is  a cast  of  the  pelvis  (now  so  well  known  from  the  copies 
having  been  multiplied  to  a great  extent)  of  Isabel  Redman,  on  whom  Dr. 
Hull  performed  the  Caesarean  operation  on  Sept.  22,  1794.  A single 
glance  will  show  its  extreme  deformity;  to  demonstrate  which,  it  is 
only  necessary  to  mention  that  a ball  of  one  inch  in  diameter  will  not  pass 
through  the  brim  at  any  part.  I believe  this  is  the  smallest  pelvis,  as  far 
as  regards  the  brim,  on  record. 

Fig.  24,  Plate  VII.  represents  the  bony  pelvis  of  a woman,  the  subject 
G 


42 


DEFORMED  PELVES. 


of  one  of  the  late  Mr.  Barlow’s  cases  of  the  same  operation ; by  whom  the 
preparation  was  presented  to  me.  From  the  junction  of  the  fourth  and 
fifth  lumbar  vertebrae  (which  is  the  most  projecting  point,  in  consequence 
of  the  sacral  promontory  being  thrust  down  considerably  lower  than  the 
level  of  the  pubes)  to  the  outer  surface  of  the  symphysis  pubis,  is  three 
inches ; the  clear  space  within  being,  from  the  same  point  to  the  ramus  of 
the  pubes  on  the  right  side,  seven-eighths  of  an  inch,  on  the  left  side,  an 
inch  and  three-eighths ; from  the  same  point  to  the  acetabulum  on  the 
right  side,  three  quarters  of  an  inch,  on  the  left  side  an  inch  and  a quarter. 
The  greatest  quantity  of  available  room  in  the  antero-posterior  diameter, 
is  from  the  left  side  of  the  sacral  promontory  to  the  ilium,  and  measures 
an  inch  and  a half.  The  greatest  lateral  space  following  the  curve,  is 
five  inches  and  three-eighths ; at  the  outlet,  the  ascending  rami  of  the  ischia 
are  in  close  contact,  and  the  centre  of  the  tuberosities  are  an  inch  and  a 
half  distant ; the  sacrum  just  below  its  centre  is  curved  at  an  acute  angle 
upwards,  so  as  to  bring  the  apex  of  the  coxyx  to  within  an  inch  and  a 
half  of  the  promontory  of  that  bone,  and  two  and  a half  to  the  point  where 
the  two  rami  of  the  ischia  touch  each  other.  Although  the  operations 
undertaken  in  both  these  instances  proved  fatal,  nobody  can  deny  the 
necessity  and  propriety  of  their  performance. 

Fig.  25,  in  the  same  Plate,  VII.,  is  taken  from  the  lithographic  drawing 
in  the  work  of  M.  Moreau,  now  in  the  course  of  publication.  It  is  intro- 
duced here  for  its  rarity.  The  original  is  in  the  anatomical  collection  in 
the  Maison  d’Accouchemens  at  Paris ; but  I have  not  been  able  to  meet 
with  a similar  specimen  in  London.  Two  or  three  may  be  found  in  which 
a tendency  to  this  figure  exists,  though  in  a very  slight  degree;  and  one 
is  preserved  in  the  University  College  Hospital  that  very  much  resembles 
it.  That,  however,  is  a male  pelvis,  and  the  deformity  was  occasioned  by 
fracture ; this  is  a female,  and  the  cause  was  disease. 

Plate  VIII.  demonstrates  the  elliptical  variety  of  distortion  from  casts. 
In  fig.  26,  the  distance  between  the  symphysis  pubis  and  sacrum  is  one 
inch  and  a half ; on  the  right  side  of  the  sacral  promontory  in  the  antero- 
posterior diameter  there  are  two  inches ; on  the  left  side,  only  three-fourths 
of  an  inch.  The  lateral  diameter  of  the  brim  following  the  curve  in  a 
central  line  equidistant  from  the  sacrum  and  pubes,  measures  six  inches 
and  a quarter ; at  the  outlet,  the  extreme  width  between  the  ischia  is  five 
inches  and  a half;  from  the  apex  of  the  coxyx  to  the  under  part  of  the 
symphysis  pubis,  four  and  a half.  Through  a pelvis  of  this  form  and 
size  the  foetus  might  be  extracted  by  the  instruments  adapted  to  crani- 
otomy. 

The  original  of  fig.  27,  is  much  smaller,  and  I fear,  if  such  a conforma- 
tion existed,  the  child  could  only  be  extricated  by  the  abdominal  incision. 


DEFORMED  PELVES. 


43 


In  this  instance,  from  the  pubes  to  the  sacrum  measures  no  more  than 
three-fourths  of  an  inch ; on  the  right  side  of  the  sacral  promontory  there 
is  one  inch  and  a quarter ; on  the  left  side,  an  inch  and  five  eighths.  At 
the  outlet,  the  tuberosities  of  the  ischia  are  four  inches  and  an  eighth 
asunder ; but  the  space  between  the  apex  of  the  coxyx  and  the  under  part 
of  the  symphysis  pubis  is  only  two  inches. 

These  examples  will  be  sufficient  to  give  an  idea  of  the  great  alteration 
which  the  pelvis  undergoes  when  its  bony  structure  is  attacked  by  disease ; 
it  is  needless,  therefore,  to  adduce  a larger  number. 


pi  m 


< * 


\\  l \b'niC 


•V 


% 


* 


OF  PELVIMETERS. 


Plate  IX. 

Much  ingenuity  has  been  displayed  by  our  Gallic  neighbours  in  the 
invention  of  instruments  for  the  purpose  of  measuring  the  conjugate  diame- 
ter of  the  pelvis  at  the  brim ; and  Coutouli’s  pelvimeter,  and  Baudelocque’s 
calipers,  are  those  best  known.  The  former  consists  of  a flat  base  and  a 
moveable  slide,  into  which  it  is  fitted ; at  the  end  of  both  the  base  and  the 
slide  a piece  of  metal  projects  at  right  angles.  This  instrument,  indeed, 
resembles  that  by  which  shoemakers  are  accustomed  to  measure  the 
length  of  the  foot : it  is  to  be  introduced  within  the  vagina ; the  extremity 
of  the  base  is  to  be  carried  up  to  the  promontory  of  the  sacrum,  and  the 
projection  at  the  end  of  the  slide  brought  behind  the  symphysis  pubis.  By 
a scale  which  hangs  out  beyond  the  external  parts,  the  space  between  the 
apex  of  the  pubic  arch  and  sacrum  may  be  known.  Making,  then,  an 
allowance  for  the  difference  between  the  oblique  and  direct  diameter, 
it  was  supposed  we  might  become  acquainted  with  the  actual  available 
space  there  existing.  This  contrivance  is  easily  adapted  to  a skeleton 
pelvis,  and  so  would  a common  rule  be ; but  its  application  when  the  soft 
parts  are  preserved,  is  difficult;  and,  from  its  straight  figure,  impossible, 
if  any  part  of  the  child’s  head  be  engaged  in  the  pelvic  brim.  As,  there- 
fore, that  pelvis  must  be  exceedingly  distorted  which  would  not  allow  the 
head  to  descend  somewhat  into  the  cavity,  Coutouli’s  pelvimeter  is  found 
practically  valueless. 

The  compas  d’epaisseurs,  or  calipers  of  Baudelocque,  are  intended  to 
be  applied  externally  to  the  woman’s  person.  They  consist  of  a base  or 
handle,  formed  of  two  parallel  pieces,  and  joined  at  their  lower  extremity 
by  a hinge ; from  the  upper  end  of  the  handle  two  curved  arms  rise,  having 
at  their  points  two  small  buttons.  One  of  these  is  to  be  placed  upon  the 


46 


PELVIMETERS. 


outer  surface  of  the  symphysis  pubis, — the  mons  veneris ; and  the  other 
on  the  lower  end  of  the  loins,  opposite  to  the  sacral  promontory.  A scale 
of  inches  is  adapted  to  the  handle,  and  so  calculated,  that  it  is  supposed 
to  indicate  the  exact  space  between  the  promontory  of  the  sacrum,  and 
pubes  within  the  pelvis.  This  may,  perhaps,  be  perfectly  true  in  regard 
to  a standard  pelvis,  or  one  deviating  but  little  from  the  ordinary  size ; but 
no  person  can  regard  the  various  specimens  of  deformity  shown  in  the 
plates,  without  being  perfectly  convinced  that,  if  taken  as  our  guide  in 
all  cases  of  distortion,  it  would  afford  the  most  conflicting  and  erroneous 
results. 

In  Plate  IX.,  fig.  28,  the  application  of  both  these  mechanical  inventions 
is  sufficiently  well  displayed  to  require  no  farther  illustration. 

Such  contrivances  for  the  purpose  of  measuring  the  pelvic  brim  have 
by  no  means  met  with  the  sanction  of  British  practitioners  in  general ; but 
they  are  in  the  habit  of  depending  for  this  information  on  examinations 
conducted  by  the  fingers,  or  the  hand.  Three  methods  are  practised: 
one  is,  by  the  introduction  of  the  first  finger  of  the  right  hand  within  the 
vagina,  so  that  the  point  should  be  carried  up  to  and  touch  the  sacral  pro- 
montory, while  the  root  of  the  finger  is  applied  exactly  under  the  symphy- 
sis pubis,  at  the  upper  part  of  the  arch,  Plate  IX.  fig.  29.  It  must  be  evi- 
dent that  this  mode  of  inquiry  will  be  of  no  avail  unless  the  pelvis  be 
greatly  distorted,— considerably  under  three  inches,  indeed,  in  the  conju- 
gate diameter.  For  the  ordinary  length  of  the  index  finger  along  its 
inner  edge,  is  less  than  three  inches ; and  as  the  oblique  line  from  the  pro- 
montory to  the  apex  of  the  pubic  arch  exceeds  the  direct  line  across,  so 
if  there  be  more  than  the  space  just  mentioned,  the  finger  would  not  be 
able  to  reach  the  projection,  and  we  should  consequently  be  in  utter  igno- 
rance what  amount  of  room  existed.  If  the  pelvis  be  very  small,  the 
sacral  .promontory  can  be  felt  with  ease;  but  even  in  that  case  the  dimen- 
sion of  the  direct  conjugate  diameter  is  not  afforded,  but  the  length  of  the 
oblique  line  is  given ; and  it  is  not  always  possible  to  calculate  the  diffe- 
rence between  these  two  lines  accurately. 

Another  mode  which  has  been  recommended  is  the  introduction  of  the 
whole  left  hand  within  the  pelvis,  with  the  outside  or  point  of  the  little 
finger  touching  the  inner  surface  of  the  symphysis  pubis,  and  the  first 
finger  placed  against  the  promontory  of  the  sacrum.  As  every  man  is 
aware  what  his  hand  measures  across,  it  is  supposed  he  will  be  able  to 
ascertain  the  transverse  width  of  the  pelvis.  Thus,  presuming  the  hand 
to  be  two  inches  and  three-quarters  wide,  which  is  the  common  average 
about  the  centre  of  the  fingers,  if,  when  placed  edgeways,  it  just  fits  the 
brim,  the  examiner  will  know  that  the  space  is  within  three  inches.  Again, 
if  he  can  only  introduce  three  fingers  instead  of  four,  he  will  know  that 


PELVIMETERS. 


47 


the  pelvis  does  not  measure  two  inches,  and  probably  not  so  much  ; and 
if  he  can  only  pass  up  two  fingers,  closed  together,  he  will  be  assured  that 
there  is  not  more  than  an  inch  and  three-eighths.  But,  on  the  contrary, 
if,  on  introducing  the  whole  hand,  he  be  compelled  to  spread  his  fingers 
widely  before  he  can  touch  the  sacral  promontory,  he  will  then  be  certain 
that  the  space  is  more  than  three  inches,  probably  four,  or  near  it.  (Plate 
IX,  fig.  30.) 

But  it  is  not  always  easy  to  follow  this  mode  of  inquiry,  because  the 
child’s  head  is  generally  protruded  somewhat  into  the  pelvis,  even  when 
the  brim  is  contracted ; and  we  could  not  carry  the  hand  up  in  this  man- 
ner, and  make  the  accurate  examination  which  we  require  to  do  unless 
the  brim  as  well  as  the  cavity  were  perfectly  free  and  unoccupied.  It 
might,  perhaps,  be  employed  with  advantage,  provided  the  deformity  were 
excessive. 

The  third  method  I consider  the  best,  and  is  the  one  I myself  adopt. 
Two  fingers  of  the  left  hand  are  to  be  carried  within  the  vagina ; the  extre- 
mity of  the  first  finger  is  to  be  placed  exactly  behind  the  symphysis  pubis, 
and  the  tip  of  the  second  against  the  sacral  promontory.  Plate  IX,  fig. 
31.  By  stretching  the  fingers  in  this  way,  we  shall  have  little  difficulty 
in  reaching  the  promontory  of  the  sacrum,  even  when  the  pelvis  is  of  ordi- 
nary dimensions;  and  by  withdrawing  them  in  the  same  position,  we  may 
measure  off  the  distance  between  their  extremities  on  the  first  finger  of 
the  right  hand,  or  on  a scale  of  inches,  as  with  the  limbs  of  a pair  of  com- 
passes; and  consequently  we  arrive  at  an  accurate  knowledge  of  the  exact 
dimensions  of  the  pelvic  brim.  The  laxity  of  the  vagina,  and  other  soft 
structures,  which  almost  invariably  attends  the  process  of  labour,  will  per- 
mit the  fingers  to  be  withdrawn  extended ; and  if  the  examiner  uses  suffi- 
cient care,  they  may  be  kept  perfectly  steady  until  the  space  which  they 
embrace  be  ascertained. 

This  mode  of  proceeding  possesses  a great  advantage  over  the  other 
two,  inasmuch  as  we  are  able  equally  well  to  make  our  examination, 
whether  the  head  be  occupying  a part  of  the  pelvic  cavity,  or  whether  it 
be  still  detained  quite  above  the  brim ; for  even  if  it  be  engaged  in  the 
vagina,  one  finger  may  be  passed  anterior  to,  and  the  other  behind  it,  with 
comparative  ease. 

But  although  in  most  instances  the  brim  demands  the  principal  part  of 
our  attention,  the  shape  and  capacity  of  the  cavity  and  outlet  must  not  be 
neglected.  To  inform  ourselves  on  these  points,  the  fingers  being  gently 
carried  along  the  hollow  of  the  sacrum,  notice  must  be  taken  of  the  degree 
of  curvature  which  that  bone  possesses,  and  of  the  mobility  of  the  coxyx. 
The  width  between  the  tuberosities  of  the  ischia,  as  well  as  the  inclina- 


48 


OF  PRETERN ATUR ALL Y 


tion  of  the  spinous  processes,  must  also  be  made  the  subject  of  obser- 
vation. 

We  may  suspect  that  the  pelvis  is  deformed  if  the  spine  be  very  much 
curved,  and  particularly  if  with  that  distortion  the  thigh-bones  be  bent 
considerably ; for  in  such  case  we  may  fairly  infer  that  the  curvature  of 
the  spinal  column  has  not  arisen  from  any  local  disease  of  the  vertebrae, 
but  from  some  general  constitutional  affection,  such  as  rickets,  or  mollities 
ossium ; and  when  the  system  is  influenced  to  any  great  extent  by  either 
of  these  diseases,  we  cannot  expect  that  the  pelvis  will  escape  derange- 
ment. 

It  must  be  borne  in  mind,  nevertheless,  that  any  opinion  we  may  enter- 
tain as  to  the  pelvic  capacity  from  the  general  form  will,  at  the  best, 
amount  only  to  suspicion ; for  however  crooked  the  spine  may  be,  it  by  no 
means  necessarily  follows  that  the  pelvis  is  distorted. 

It  is  by  internal  examination  alone, — and  that  during  labour, — that  we 
can  obtain  any  positive  information  as  to  the  state  of  the  pelvis.  We  may, 
indeed,  in  cases  of  great  deformity,  even  at  other  times,  detect  the  projec- 
tion of  the  sacral  promontory,  or  the  approximation  of  the  ischia,  by  the 
introduction  of  one  or  two  fingers  into  the  vagina ; but  an  accurate  know- 
ledge of  the  pelvic  dimensions  can  only  be  gained  when  the  soft  structures 
are  relaxed  by  the  process  of  parturition. 

Of  preter naturally  large  pelves . — From  what  has  been  already  advanced, 
it  will  be  readily  conceded  that  few  greater  evils  could  befall  a child-bear- 
ing woman  than  to  be  the  subject  of  a contracted  pelvis;  and  it  might  be 
supposed,  therefore,  that  the  possession  of  a very  large  one  was  to  be 
esteemed  a great  blessing.  But  this  is  far  from  being  the  case ; and  an 
organ  much  exceeding  the  standard  proportions  must  be  regarded  as  very 
liable  to  entail  danger  both  on  the  mother  and  her  offspring. 

One  of  the  most  common  accidents  to  which  a woman  with  a preter- 
naturally  large  pelvis  is  exposed,  is  the  descent  of  the  gravid  womb. 
When  a certain  period  of  pregnancy  has  passed,  the  uterus,  which  before 
that  time  had  remained  within  the  pelvic  cavity,  rises  by  degrees  through 
the  brim,  and  occupies  a portion  of  the  abdomen.  By  this  change  in  its 
situation,  the  viscera,  blood-vessels,  and  nerves  at  the  lower  part  of  the 
trunk,  are  relieved  from  the  pressure  they  had  been  previously  exposed 
to.  But  whenever  the  pelvis  is  sufficiently  capacious  to  give  it  lodgment 
for  a longer  duration  than  should  be,  it  sinks  by  its  own  weight  lower 
than  it  ought,  and  much  inconvenience  is  felt  from  its  subsidence.  In 
some  cases,  moreover,  the  gravid  womb  has  been  known  to  prolapse 
beyond  the  external  parts,  hanging  as  a large  tumour  between  the  thighs, 


LARGE  PELVES. 


49 


inverting  the  vagina,  and  dragging  down  with  it  both  the  bladder  and  the 
rectum.  Abortion  is  likely  to  be  excited  by  such  an  occurrence;  and  thus 
a preternaturally  large  pelvis  may  lead  both  to  the  loss  of  the  ovum,  and 
to  chronic  and  confirmed  prolapsus  uteri. 

Another  distressing  and  dangerous  accident  to  which  a woman  posses- 
sing a very  large  pelvis  is  generally  supposed  to  be  peculiarly  obnoxious, 
consists  in  the  retroversion  of  the  pregnant  womb ; — when  the  fundus, 
instead  of  mounting  towards  the  abdomen,  is  turned  back  upon  the  pro- 
montory, or  falls  down  into  the  hollow  of  the  sacrum.  To  a certain 
extent,  this  position  is  true ; for  retroversion  of  the  uterus  is  more  likely  to 
happen  in  a case  of  excessive  capacity  than  where  the  organ  is  near  the 
standard  size.  But  by  far  the  greater  number  of  instances  of  this  descrip- 
tion which  have  come  under  my  observation  have  been  combined  with  a 
slight  diminution  of  space  in  the  conjugate  diameter  at  the  brim ; and  I 
am  therefore,  warranted  in  concluding-  that  such  a formation  more  fre- 
quently predisposes  to  this  cause  of  danger  than  an  undue  capacity. 

A third  inconvenience,  and  one  of  no  trifling  importance,  is  the  rapidity 
with  which  a foetus  will  sometimes  be  expelled  through  a pelvis  of  extra- 
ordinary dimensions.  Provided  the  os  uteri  be  widely  open,  the  other 
soft  parts  lax  and  distensible,  and  the  uterine  energies  are  exerted  vigor- 
ously, the  child  may  be  expelled  so  quickly  that  no  assistance  can  be  ren- 
dered ; under  circumstances,  too,  in  which  both  its  own  life  and  its  mother’s 
must  be  brought  into  imminent  peril. 


7 


■mW< 


<5  in.  c/rJH'S  Litfl. 


FEMALE  GENERATIVE  ORGANS. 


The  female  organs  of  generation  are  classed  in  two  divisions — external 
and  internal. 

The  external  consist  of  the  mons  veneris,  labia  externa,  'perineum, 
clitoriswith  its  prepuce,  nymphce,  vestibule,  meatus  urinarius,  hymen  in 
virgins,  and  carunculce  myrtiformes  in  matrons. 

The  internal  are,  the  vagina,  uterus,  and  uterine  appendages ; which 
latter  consists  of  two  broad  ligaments,  two  round  ligaments,  two  ovaries, 
and  two  fallopian  tubes. 

EXTERNAL  ORGANS. 


Plate  X. 

At  the  lowest  part  of  the  abdomen,  lying  immediately  over  the  pubes, 
is  situated  a soft  cushion-like  eminence,  about  three  inches  in  breadth,  and 
two  in  depth,  called  the  mons  veneris,  plate  X.,  (a.)  It  is  formed  of  a large 
quantity  of  loose  cellular  tissue,  the  interstices  of  which  are  filled  up  with 
much  adipose  matter ; it  is  covered  by  the  common  cuticle  of  the  body ; 
and  at  puberty,  studded  with  a number  of  short  capilli,  among  the  roots  of 
which  are  embedded  numerous  mucous  follicles. 

Arising  from  the  mons  veneris,  and  running  down  perpendicularly,  to 
unite  at  a junction  below,  there  are  two  pouting  lips,  the  labia  externa, 
or  labia  pudendi,  ( b .)  In  length  they  are  about  three  inches,  and  in  struc- 
ture they  exactly  resemble  the  mons  veneris.  The  commissure  at  which 


52 


EXTERNAL  ORGANS. 


they  join  is  called  the  fourchette,  (c.)  It  is  somewhat  similar  in  appear- 
ance to  the  continuation  of  the  skin  at  the  roots  of  the  fingers,  and  is  the 
anterior  boundary  of  the  perineum. 

The  perineum  (d)  extends  from  the  lower  union  of  the  labia  externa 
back  towards  the  anus  ( e .)  Its  structure  is  principally  made  up  of  highly 
distensible  cellular  membrane ; it  does  not  possess  in  its  substance  a great 
deal  of  fat,  and  the  skin  is  but  scantily  furnished  with  hair.  Its  length  is 
about  an  inch  or  an  inch  and  a quarter  in  the  quiescent  state  of  the  parts  ; 
but  when  the  child’s  head  is  pressing  externally  in  labour,  it  is  capable  of 
elongation  to  three,  four,  or  even  five  inches ; and  in  the  same  degree  that 
it  is  extended  in  surface  it  becomes  thinned  in  substance.  It  is  to  this 
part  of  the  body  that  the  obstetrician,  during  natural  labour,  is  required  to 
direct  a principal  part  of  his  attention,  for  the  purpose  of  preventing 
laceration  and  injury.  These  parts,  closing  and  surrounding  the  genital 
fissure,  altogether  constitute  the  pudendum. 

On  separating  the  labia  externa,  a line  of  demarcation  is  distinctly 
evident  in  each,  where  the  skin  of  the  body  terminates,  and  the  mucous 
membrane  investing  the  organs  within  commences.  This  continuation  of 
the  mucous  into  the  cuticular  structure  is  exactly  similar  to  the  arrange- 
ment observable  in  the  openings  of  other  cavities — as  the  anus,  nose,  and 
male  urethra.  A hollow  is  also  observed,  which  in  the  virgin  is  bounded 
posteriorly  by  the  hymen.  This  has  obtained  the  name  of  concha,  or 
fossa  navicularis,  and  it  contains  within  its  precincts  the  clitoris  with  its 
prepuce,  the  nymphse,  the  vestibule,  and  the  meatus  urinarius.  The  whole 
of  the  external  parts  together,  as  well  those  that  are  lined  by  mucous 
membrane,  as  those  covered  by  the  common  cuticle,  are  called  the  vulva. 

The  clitoris,  (/,)  or  rather  that  portion  of  it  which  is  visible,  is  placed 
rather  above  and  anterior  to  be  lower  edge  of  the  symphysis  pubis.  In 
formation  it  bears  a great  analogy  to  the  male  penis : it  resembles  it,  indeed, 
in  every  respect,  except  two — its  small  size,  and  its  not  being  permeated 
by  the  urethra.  Like  the  male  penis,  it  is  composed  of  two  crura , which 
arise  from  the  rami  of  the  ischia  and  pubes,  one  on  each  side,  run  up  to 
the  junction  of  the  bones  at  the  symphysis,  and  there  form  the  corpora 
cavernosa.  These  are  also  furnished  with  two  muscles  resembling  the 
erectores  penis  in  the  male.  At  the  extremity  of  the  corpora  cavernosa 
is  placed  the  glans  ; this  is  the  only  part  of  the  organ  that  we  can  observe 
by  the  eye,  the  others  being  embedded  between  the  mucous  membrane 
and  the  bone.  Above  the  glans  projects  a duplicature  or  fold  of  mem- 
brane, covering  it  like  a hood — apparantly  for  the  purpose  of  protection 
— the  preputium  clitoridis,  (g.)  The  clitoris  is  the  most  sensitive  part  of 
all  the  external  organs.  It  is  capable  of  distention,  as  the  male  penis  is. 


EXTERNAL  ORGANS. 


53 


It  is  liberally  supplied  with  blood  from  the  pudic  artery ; and  with  nerves 
from  branches  of  the  pudic  fasciculi. 

Taking  their  origin  from  the  clitoris,  and  sometimes  arising  from  its 
prepuce,  there  are  two  other  distinct  folds  of  mucous  membrane,  which 
run  parallel  to  the  labia  externa — the  nympho,  or  labia  interna  ( h .) 
They  are  nothing  more  than  membranous  rugae — two  layers  connected 
by  cellular  substance — and  at  their  termination  they  are  ultimately  lost  in 
the  lining  membrane  of  the  parts.  They  are  mechanically  opened  out 
during  the  passage  of  the  foetal  head  in  labour,  and,  by  affording  an 
increase  of  surface,  assist  in  preventing  laceration  of  the  membrane. 

Between  the  two  nympha),  running  downwards  and  inwards  round  the 
lower  edge  of  the  symphysis  pubis,  and  leading  directly  to  the  meatus 
urinarius,  a smooth  groove,  of  about  an  inch  in  length,  is  situated,  termed 
the  vestibule,  (z.)  The  surgeon  will  find  it  highly  necessary  to  pay 
attention  to  this  furrowed  depression,  because  in  the  introduction  of  the 
catheter  it  guides  his  finger  to  the  entrance  of  the  urethra. 

The  Meatus  Urinarius,  (&,)  the  mouth  of  the  urethra,  which  is  the 
canal  leading  to  the  bladder,  is  situated  at  the  farther  extremity  of  the 
vestibule.  It  is  a small  closed  aperture,  capable  of  admitting  with  ease 
the  barrel  of  a goose  quill;  and  is  so  distensible  that  a much  larger 
cylinder  can  be  introduced.  It  is  essential  that  we  become  acquainted, 
not  only  with  the  situation  of  this  aperture,  but  with  the  character  which 
it  affords  to  the  touch ; because  when  the  bladder  requires  to  be  artificially 
evacuated,  it  is  most  desirable  that  the  instrument  used  for  that  purpose 
should  be  passed  in  by  the  aid  of  the  finger  alone,  without  exposing  the 
woman’s  person  to  the  eye.  This  operation  is  frequently  required,  as 
well  under  labour  as  under  different  states  of  organic  disease  and  func- 
tional derangement.  In  the  more  natural  state  of  the  parts  we  shall  find 
the  meatus  to  consist  of  an  eminent,  soft,  circular  rim,  with  a central 
depression,  that  would  appear  scarcely  large  enough  to  permit  the  insertion 
of  a small  wire ; and  if  its  position  is  borne  in  mind,  a little  practice  will 
enable  the  student  to  introduce  the  catheter  with  facility.  But  when  the 
structures  are  pressed  upon  by  a long-continued  lodgment  of  the  child’s 
head  in  the  pelvis  under  labour,  such  a confusion  is  occasioned  by  their 
extension  or  tumefaction,  that  the  peculiar  character  of  this  part  is  lost, 
and  much  difficulty  may  be  experienced  both  in  detecting  it,  and  guiding 
the  instrument  into  it.  In  such  case,  it  is  infinitely  better  to  expose  the 
patient  to  the  inconvenience  of  an  ocular  inspection  than  to  allow  the 
bladder  to  become  over-charged,  to  the  imminent  risk  of  its  bursting,  or 
to  the  no  less  probable  chance  of  a fistulous  orifice  being  formed  between 
its  neck  and  the  vagina. 


54 


EXTERNAL  ORGANS. 


The  Hymen*  (/)  is  the  posterior  boundary  of  the  fossa  navicularis, 
and,  placed  at  the  entrance  of  the  vagina,  it  divides  the  external 
from  the  internal  organs.  It  consists  of  a very  delicate  membrane, 
generally  of  a semilunar  shape,  stretched  directly  across  the  parts, 
and  having  an  aperture  anteriorly.  Sometimes,  however,  the  opening  is 
central,  and  serrated  on  its  inner  edge ; at  others,  it  possesses  a number 
of  small  punctures,  it  is  then  called  cribriform;  and  at  others  it  is  imper- 
vious, in  which  state,  on  the  accession  of  puberty,  it  gives  rise  to  many 
very  distressing  and  dangerous  symptoms,  consequent  on  the  retention 
behind  it  of  the  menstrual  and  other  secretions. 

It  is  usually  ruptured  on  the  first  sexual  access,  but  by  no  means 
universally  so.  Upon  its  destruction  the  membrane  disappears,  and  has 
been  supposed  to  dwindle  into  a number  of  little  eminences,  which  have 
been  called,  from  their  fancied  resemblance  to  myrtle-berries,  the  cartjn- 
cul^:  myrtieormes.  Lately,  however,  it  has  been  doubted  whether  these 
carunculae  were  really  the  remains  of  the  broken  hymen ; for  it  has  been 
demonstrated  by  some  physiologists,  that  both  the  hymen  and  carunculse 
may  exist  together  in  the  same  subject,  and  that  therefore  they  are  per- 
fectly independent  formations. 

Although  the  presence  of  the  hymen  was  formerly  considered  as  a test 
of  virginity,  from  the  supposition  that  it  was  invariably  broken  on  the 
consummation  of  matrimonial  intercourse,  this  idea  has  long  been  re- 
pudiated ; for  it  is  now  well  known,  not  only  that  it  may  be  destroyed  and 
lost  from  numerous  causes  originating  in  disease  or  accident,  but  also 
that  in  some  instances  it  does  not  give  way  upon  the  first  nor  many 
subsequent  connexions,  and  even  that  pregnancy  has  taken  place  while 
this  membrane  was  entire.  So  that  its  presence  can  be  no  proof  of 
personal  chastity,  nor  its  absence  of  immorality. 

All  organs  immediately  within  the  genital  fissure  are  profusely  sup- 
plied with  blood  from  branches  of  the  internal  iliac  arteries,  and  with 
nervous  influence  from  the  pudic  filaments.  The  absorbent  vessels,  also, 
are  both  large  and  numerous,  and  communicate  with  the  sacral  and 
inguinal  glands. 


* The  name  hymen  was  adopted  after  the  Greek  word  t^av,  a membrane.  From  its  bear- 
ing most  frequently  a crescent  shape,  this  membrane  has  been  fancifully  pictured  as  the  origin 
of  the  characteristic  symbol  of  the  virgin  goddess  Diana,  as  though  she  carried  on  her  brow  the 
stamp  of  her  purity.  It  is  a pretty  poetical  idea,  but  we  can  trace  her  typical  figure  to  a 
much  more  probable  source.  Diana,  in  the  beautiful  poetry  of  the  Ijeathen  mythology,  was 
generally  identified  with  Luna;  and  it  is  by  far  more  likely  that  she  derived  this  distinctive 
emblem  from  the  crescent  moon. 


I ¥ 


m 


LIBRARY 
- OF  THE 

UNIVERSITY  Ob  ILLINOIS 


VAGINA, 


55 


INTERNAL  ORGANS. 

Plates  XI.,  XII.,  XIII.,  XIV. 

The  Vagina,  Plate  XI.  fig.  33,  (k)  and  XIII.,  fig.  45,  (r)  is  a musculo- 
membranous  canal,  running  up  the  centre  of  the  pelvis,  leading  from  the  ex- 
terna] parts  to  the  os  uteri,  in  its  progress  describing  a curve  even  greater 
than  that  of  the  sacrum  and  coxyx,  having  the  neck  of  the  bladder,  the  ure- 
trha,  andthe  symphysis  pubis  anteriorly,  and  the  rectum  behind  it.  In  length 
it  is  about  four  or  five  inches;  in  circumference  about  three.  It  varies  much, 
however,  in  different  subjects,  and  is  capable  of  extension  to  an  extra- 
ordinary degree.  In  married  women,  and  those  who  have  had  a family, 
it  is  considerably  more  capacious  than  in  virgins ; it  is  also  wider  in  the 
middle  than  at  either  extremity,  and  longer  on  its  posterior  surface  than 
anteriorly.  It  is  composed  of  three  coats — an  external,  cellular ; a mid- 
dle, muscular ; and  an  internal,  mucous.  The  external  coat  is  merely  a 
collection  of  condensed  cellular  structure,  by  which  it  is  attached  to  the 
parts  surrounding  it.  The  middle  coat  is  muscular,  and  the  fibres  fol- 
low different  directions ; some  are  longitudinal,  some  transverse,  and 
some  oblique.  The  muscular  fibres  are  much  more  numerous  at  the 
commencement  of  the  vagina  than  at  any  other  part.  Here  they  seem 
arranged  in  concentric  circles,  taking  their  origin  from  the  sphincter  ani, 
to  which  formation  anatomists  have  given  the  name  of  sphincter  vagince. 
The  internal  coat  is  mucous,  and  is  a continuation  of  the  membrane 
which  lines  the  external  parts ; it  is  collected  into  transverse,  or  rather 
oblique  rugss ; and  from  this  circumstance  it  has  also  obtained  the  name 
of  the  rugous  coat  of  the  vagina. 

These  folds  are  much  more  apparent  in  the  virgin,  than  in  women  who 
have  borne  children;  and,  like  the  muscular  fibres,  they  are  found  in  the 
greatest  number  at  the  lower  end  near  the  commencement.  In  the  inter- 
stices of  the  rugae  are  placed  a number  of  follicles,  which,  independently 
of  the  mucus  poured  out  by  the  vessels  proper  to  the  membrane  itself, 
secrete  a fluid  of  a peculiar  character.  The  membrane  is  puckered  thus, 
principally  for  the  purpose  of  allowing  the  distention  of  the  vagina  during 
the  passage  of  the  child’s  head.  The  vaginal  canal  becomes  much  con- 
tracted in  advanced  life,  and  even  in  the  virgin  presents  a smooth  surface 
within,  instead  of  the  plicated  membrane. 

This  organ  is  very  plentifully  supplied  with  blood-vessels,  with  nervous 
filaments,  and  absorbents.  It  obtains  its  blood  through  branches  of  the 
two  uterine  arteries,  which  are  given  off  from  the  internal  iliacs  or  hypo- 
gastrics.  The  common  iliacs  divide  into  two  channels,  the  external  and 


56 


UTERUS. 


internal ; the  internal  descend  into  the  pelvis,  over  the  sacro-iliac  syn- 
condroses.  From  them  arise  the  uterine  arteries,  which  run  up  one  on 
each  side  of  the  vagina,  and  in  their  course  give  off  many  transverse 
branches,  which  supply  the  vagina  itself.  Its  nerves  are  principally 
derived  from  the  sacral  plexus ; its  veins  accompany  the  arteries,  and  the 
absorbents  pass  in  two  directions,  one  division  to  the  glands  in  the 
sacrum,  and  the  other  to  those  in  the  groin.  The  vagina  is  connected 
below  with  the  external  parts  by  a continuation  of  structure ; anteriorly, 
with  the  symphysis  pubis,  the  urethra,  and  the  neck  of  the  bladder,  by 
cellular  membrane;  above,  with  the  cervix  uteri,  and  behind  it  is  attached 
to  the  rectum.  The  commissure  connecting  the  two  organs  is  called  by 
anatomists  the  recto-vaginal  septum . It  runs  down,  in  connexion  with 
the  rectum,  through  a great  part  of  its  extent ; but  the  vagina,  at  its  lower 
end,  turns  at  an  angle  forwards;  while  the  rectum,  just  before  terminating 
in  the  anus,  is  directed  somewhat  backwards,  so  that  a space  of  about  an 
inch  in  extent  is  left  between  them — the  perineum. 

The  secretion  of  the  vaginal  membrane,  in  the  ordinary  healthy  state 
of  the  parts,  is  almost  exactly  balanced  by  the  natural  absorption,  so  that 
there  is  little  or  no  exudation  externally ; but  under  peculiar  states  of 
excitement  under  some  diseases  also,  as  well  as  under  labour,  the  secre- 
tion much  exceeds  the  absorption,  and  a discharge  appears  outwardly. 

At  the  upper  part  of  the  vagina,  hanging  in  the  centre  of  the  pelvis, 
behind  the  bladder  and  before  the  rectum,  with  its  superior  edge  some- 
what peeping  up  above  the  brim  of  the  pelvis ; supported  in  this  situation 
by  two  ligaments  which  run  from  its  sides  to  the  ilea,  and  by  the  vagina, 
which  is  below,  is  situated  the  uterus,  matrix,  or  womb,  the  organ  des- 
tined to  receive,  to  afford  lodgment  and  nourishment  to,  and  eventually  to 
expel  the  ovum. 

In  shape  the  uterus  is  somewhat  triangular,  or  rather  like  a flattened 
pear ; and  it  is  observed  to  be  rounder  on  its  posterior  face  than  anteriorly, 
from  which  circumstance,  in  the  unimpregnated  state,  we  can  always  dis- 
tinguish the  right  from  the  left  side.  In  length,  it  is  about  three  inches; 
in  width,  at  the  widest  part,  it  is  about  two ; and  in  thickness  pretty  nearly 
an  inch.  It  varies,  however,  in  different  subjects,  being  in  some  degree 
larger  in  women  who  have  borne  many  children,  and  smaller  in  virgins. 
Anatomists,  for  the  facility  of  teaching,  describe  it  as  though  it  consisted 
of  four  parts ; to  the  upper  third,  they  give  the  name  of  fundus,  to  the 
middle,  the  name  of  body , and  to  the  lower  third  that  of  neck ; while  its 
opening  into  the  vagina  they  designate  the  os  uteri,  or  mouth  of  the  womb. 
The  first  three  of  these  divisions  are  perfectly  arbitrary ; there  is  no  septum 
in  the  uterus,  no  line  of  demarcation  either  externally  or  within,  by  which 
we  can  point  out  their  limits ; not  so,  however,  with  regard  to  the  os  uteri, 


UTERUS. 


57 


which  is  the  means  of  its  communication  with  the  vagina — a natural  aper- 
ture. Plate  XI.  fig.  34,  shows  the  longitudinal  section  of  the  uterus ; (a,) 
the  fundus  uteri ; ( b ,)  its  body ; (c,)  the  cervix ; ( d ,)  the  os  uteri ; (e,)  a small 
portion  of  the  upper  part  of  the  vagina.  The  central  line  shows  the  direc- 
tion of  the  cavity. 

The  uterus  is  covered  externally  by  the  peritoneum ; it  has  a cavity 
which  is  lined  by  mucous  membrane,  and  a peculiar  parenchymatous  struc- 
ture between  the  two.  The  peritoneum,  after  having  lined  the  abdominal 
muscles,  rises  over  the  bladder,  giving  a covering  to  a very  considerable 
portion  of  that  viscus ; it  then  passes  from  the  neck  of  the  bladder  directly 
backwards  to  the  cervix  uteri ; it  mounts  over  the  uterus,  and  descends  on 
the  back  part  somewhat  lower  than  in  front,  dipping  even  a little  beneath 
the  os  uteri,  affording  an  external  coat  to  a very  small  portion  of  the 
vagina,  and  separating  the  uterus  entirely  from  the  rectum ; it  is  then  con- 
tinued from  the  upper  part  of  the  vagina  to  the  lower  gut,  and  ascends  to 
embrace  the  bowels.  From  the  sides  of  the  uterus  processes  are  sent  off, 
which  constitute  the  broad  ligaments. 

The  parenchymatous  structure  of  this  organ  is  of  a very  dense  charac- 
ter, in  appearance  much  resembling  a half-tanned  hide.  On  making  a 
section  of  it,  we  observe  a great  number  of  very  minute  tortuous  vessels 
running  throughout  its  whole  substance ; in  the  unimpregnated  state  they 
are  scarcely  capacious  enough  to  receive  the  finest  injection;  but  they 
take  upon  themselves  a process  of  growth  as  soon  as  conception  has 
occurred  ; and  towards  the  end  of  pregnancy  many  of  them  are  sufficiently 
large  in  calibre  to  admit  the  introduction  of  a goose  quill. 

The  uterus  is  generally  considered  by  anatomists  of  the  present  day  as 
a muscular  organ ; and,  although  this  has  been  doubted  by  some  respect- 
able physiologists,  it  is  now  usually  classed  among  the  hollow  muscles  of 
the  body. 

This  viscus  contains  a cavity  which  is  lined  by  mucous  membrane, 
being  a continuation  of  that  lining  the  vagina.  The  membrane  is  puckered 
into  longitudinal  or  arborescent  stria;  towards  the  mouth  of  the  womb, 
more  evident  in  the  virgin  than  in  women  who  have  had  children,  Plate 
XI.  fig.  36,  ( b .)  This  formation  is  denominated  the  arbor  vitce.  In  the 
infant,  the  whole  inner  membrane  is  corrugated. 

Figure  35  Plate  XI.,  shows  the  infantile  uterus  laid  open ; ( a ,)  the 
inner  membrane  of  the  uterus ; (6,)  the  os  uteri ; (c,)  the  upper  part  of  the 
vagina. 

The  cavity  of  the  uterus  is  somewhat  similar  in  shape  to  its  external 
form ; it  is  rather  triangular,  and  large  enough  to  contain  a split  almond. 
Into  it  three  apertures  open ; — two  at  the  angles  of  the  fundus,  the  uterine 
extremities  of  the  fallopian  tubes,  and  one  below,  communicating  with  the 
8 


58 


UTERUS. 


vagina — the  mouth  of  the  womb.  The  fallopian  tubes  do  not  enter  the 
uterus  in  a straight  line,  opposite  to  each  other,  but  obliquely;  from  which 


arrangement,  two  bristles  passed  along  the  tubes  cross  each  other  at  a 


considerable  angle  when  received  into  the  cavity.  Fig.  36,  displays  the 
uterine  cavity  laid  open ; — (a,)  the  os  uteri ; (£>,)  the  cervix ; the  longitudi- 
nal lines  show  the  appearance  called  arbor  vitae ; (c,)  the  uterine  extremi- 
ties of  the  fallopian  tubes,  with  a bristle  inserted  into  each. 


The  opening  into  the  vagina  is  called  the  os  uteri , os  tincce*  os  inter- 


num, or  the  mouth  of  the  womb , and  by  it  a free  communication  is  per- 
mitted between  the  cavities  of  the  vagina  and  the  uterus.  But  it  must  not 
be  supposed  that  the  uterus  is  connected  with  the  vagina  by  a direct  con- 
tinuation of  their  separate  structures ; on  the  contrary,  the  vaginal  coats  v , 
run  up  a few  lines  above  the  orifice,  to  terminate  at  the  cervix  uteri ; ar 
the  mucous  membrane  is  reflected  over  its  mouth,  to  line  it  within ; 


that  the  os  uteri  pouts  and  projects  somewhat  into  the  vagina,  at  an  angl&? 


looking  considerably  backwards,  towards  the  centre  of  the  hollow  of  the 
sacrum,  Plate  XIII.  fig.  45,  ( q .)  In  the  adult  subject,  the  os  uteri  is  of 
an  oval  shape,  the  slit  being  lateral,  so  that  it  is  divided  into  an  anterior  ' 
and  posterior  lip.  In  the  virgin  it  will  with  difficulty  admit  the  extremity 
of  a flattened  catheter ; but  it  is  generally  more  dilated  in  women  who  have 
had  children,  in  whom  also  it  is  often  fissured.  Thickly  studding  the  os  : 
uteri,  as  also  the  cervix,  we  observe  a number  of  follicles,  called  glandulce 
JVabothi,  Plate  XX.  figs.  68,  69,  70.  These  are  scarcely  perceptible  in 
the  healthy  uterus  of  the  virgin ; but  they  enlarge  much  under  pregnancy, 
during  which  state  they  become  very  evident  to  the  eye.  With  this  in- 
crease of  size,  a new  office  is  afforded  them ; they  pour  out  a thick,  tough, 
pellucid,  gelatinous  mucus  in  considerable  quantities,  which  blocks  up  the 
entrance  to  the  cavity  of  the  uterus,  and  breaks  off  the  communication 
between  it  and  the  vagina ; and  as  long  as  this  mucus  remains  in  situ , no 
fluid  can  be  injected  into  the  uterus.  Plate  XVI.  fig.  56,  is  designed  to 
show  the  appearance  of  this  mucus  at  the  cervix  uteri. 

The  uterus  is  very  liberally  supplied  with  blood-vessels,  with  nerves  and 
absorbents.  The  arteries  are  from  two  sources ; one  set,  the  spermatic , 
descend  from  the  aorta,  below  the  renal  arteries,  sometimes  by  one  trunk 
from  the  anterior  part  of  that  vessel,  and  sometimes  by  two,  one  on  each 
side : at  others,  they  have  been  known  to  take  their  origin  from  the  renal 
arteries.  They  descend  with  the  same  tortuous  inflections  as  the  sper- 
matic vessels  in  the  male,  supply  the  ovaries,  and  afterwards  run  along 
the  broad  ligaments,  to  expend  themselves  in  the  uterus ; — the  other,  the 
uterine , are  given  off  from  the  internal  iliacs,  and  anastomose  very  freely 


* Os  tinea:,  from  ils  fancied  resemblance  to  the  mouth  of  a tench  fish. 


PL  XL 


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CNIVElfsn  1-OF  !LL!NO!r 


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OVARIES. 


59 


with  the  uterine  branches  of  the  spermatic.  By  these  two  sets  of  vessels,  a 
very  copious  supply  of  blood  is  allowed — one  originating  high  up  in  the  loins, 
and  the  other  low  down  in  the  pelvis.  The  veins  follow  the  course  of  their 
respective  arteries.  The  spermatic  have  the  same  termination  as  the  sper- 
matic veins  in  the  male — the  right  in  the  inferior  cava,  the  left  in  the  renal 
vein.  The  uterine  veins  empty  themselves  into  the  internal  iliacs.  The 
nerves  also  are  from  two  sources:  one  supply  is  derived  from  the  sacral  plex- 
us of  the  cerebro-spinal  system,  the  other  from  the  great  sympathetic ; and  it 
is  through  the  filaments  of  the  latter  nerve  that  most  of  the  vital  organs  of 
the  body,  especially  the  stomach,  sympathize  so  completely  with  the 
uterus,  as  well  under  disease  as  under  pregnancy.  The  absorbents  also 
run  in  two  directions,  one  into  the  lumbar  and  sacral  glands,  and  the 
other  through  the  round  ligament  into  the  glands  of  the  groin.  The  con- 
nexions of  this  organ  are  with  the  sides  of  the  pelvis,  by  the  broad  liga- 
ments which  principally  support  it ; with  the  vagina  inferiorly ; with  the 
neck  of  the  bladder  anteriorly,  by  cellular  substance;  and  with  the  groin, 
by  means  of  the  round  ligament.  It  cannot  be  said  to  be  connected  with 
the  rectum,  because  the  peritoneum  dips  down  sufficiently  low  to  separate 
it  perfectly  from  that  gut,  giving  an  outward  tunic  to  a small  portion  of 
the  upper  part  of  the  vagina.  In  this  respect  the  posterior  differs  mate- 
rially from  the  anterior  surface  of  the  uterus,  because  there  is  a direct 
connexion  in  front  between  the  cervix  uteri  and  the  neck  of  the  bladder 
by  cellular  tissue. 

From  each  side  of  the  uterus  two  duplicatures  of  the  peritoneum  extend 
to  the  ilea.  They  are  called  the  broad  ligaments,  and  sometimes,  from 
their  shape — since  they  are  fancifully  supposed  to  spread  out  somewhat 
like  the  wings  of  a bat — the  alas  vespertilionis.  They  contain  the  fallopian 
tubes,  which  run  on  their  upper  margin ; the  ovaries,  which  are  enclosed  in 
a posterior  fold;  the  round  ligaments  on  their  anterior  face;  and  blood-ves- 
sels, nerves,  and  absorbents,  destined  to  supply  the  uterus  itself.  These  liga- 
ments are  well  seen  in  Plate  XI.  fig.  33,  (e  e ;)  the  right  is  shown  in  Plate 
XIII.  fig.  45,  (m.)  There  is  also  another  double  extension  of  the  peritoneum 
on  each  side,  not  usually  described  by  anatomists,  arising  from  the  angle 
of  the  fundus  uteri,  and  running  backwards  to  the  sacrum  and  lumbar 
vertebras.  These,  in  conjunction  with  the  lateral  ligaments,  are  for  the 
purpose  of  supporting  the  uterus  in  its  situation,  while  hanging  in  the  centre 
of  the  pelvis,  and  of  guiding  it  in  its  ascent  to  the  abdomen  during  the 
middle  months  of  pregnancy,  Plate  XIII.  fig.  46,  ( h h.) 

Dangling  somewhat  loosely  between  the  duplicatures  of  the  broad  liga- 
ment posteriorly,  at  the  distance  of  about  an  inch  and  a half  from  the 
edge  of  the  uterus,  on  each  side,  are  placed  the  ovaria,  Plates  XI.  fig.  33, 
(i  if)  XIII.  fig.  45,  (l  /,)  and  fig.  46,  (g  g.)  They  are  oval,  glandular 


60 


CORPUS  LUTEUM. 


bodies,  about  the  size  of  a large  almond ; and  previously  to  the  time  of 
Steno,  who  first  asserted  that  they  were  analogous  to  true  ovaria,  they 
were  called  the  female  testes.  Enclosed  within  this  fold,  they  obtain 
their  external  covering  from  the  peritoneum ; their  surface  in  consequence 
is  smooth  and  shining.  Besides  the  peritoneal  coat,  they  possess  beneath 
it  another, — their  proper  tunic  ; and  an  impervious  cord  extends  from  each 
to  the  side  of  the  uterus, — the  ligament  of  the  ovary.  When  a section  is 
made,  their  structure  is  found  to  consist  of  dense  cellular'tissue,  in  which 
is  imbedded  a number  of  small  cavities  or  vesicles,  varying  in  size  from 
the  minutest  pin’s  head  to  that  of  a large  shot,  the  lesser  being  within, 
the  larger  more  towards  the  surface.  The  fluid  which  these  cavities  con- 
tain is  pellucid  and  coagulable  by  alcohol,  heat,  and  the  strong  acids — 
composed,  therefore,  principally  of  albumen.  In  number  they  vary  from 
twelve  to  fifteen  in  each  ovarium.  They  are  called,  after  De  Graaf,  vesi- 
culce  Graafiance.  We  may  remark  them  sometimes  rather  eminent  upon 
the  surface.  In  the  course  of  my  dissections,  I have  occasionally  seen 
two  or  three  projecting  under  the  peritoneum,  studding  the  external  face 
of  the  gland  like  beautiful  little  pearls,  and  on  pricking  them  the  fluid  has 
exuded.  We  do  not  see  these  vesicles  at  all  before  puberty  ; they  disap- 
pear, or  become  altered  towards  the  close  of  life,  when  the  gland  is  shri- 
velled by  age ; and  are  found  in  the  greatest  number,  and  most  apparent, 
in  the  adult  virgin.  The  vesiculm  Graafianae  contain  whatever  the  female 
supplies  towards  the  formation  of  the  embryo.  The  late  researches,  in- 
deed, of  the  talented  and  indefatigable  Baer  have  detected  in  the  vesicle 
before  impregnation  a minute  body  of  spheroidal  shape,  which  is  admitted 
by  those  physiologists  who  have  most  deeply  studied  the  subject  since  this 
discovery  was  made,  to  be  perfectly  similar  in  all  its  essential  qualities  to 
the  ovum  of  birds  and  other  ovipara.  It  is  presumed  to  be  the  germ  from 
whence  will  spring 'the  future  man,  being  vivified  by  the  mysterious 
agency  of  the  male  semen  during  the  process  of  conception. 

Corpus  Luteum. — In  the  ovary  of  a woman  recently  pregnant,  we 
observe,  besides  these  vesicles,  a vascular  spot  about  the  size  of  a large 
pea  or  small  bean,  containing  a central  cavity,  sometimes  empty,  at  others 
filled  with  coagula,  the  consequence  of  the  late  conception.  It  is  some- 
what fabiform,  of  a dull  yellow  tint,  resembling  in  hue  the  buffy  coat  of 
the  blood,  and  when  newly  exposed,  slightly  red.  The  name  corpus  luteum 
was  given  to  it  by  Malpighi,  from  its  colour;  it  had  been  previously  called 
by  De  Graaf  corpus  glandulosum,  for  it  possesses  much  of  a gland-like 
appearance.  Hunter,  indeed,  described  it  as  “ tender  and  friable,  like 
glandular  flesh.”  Rcederer  compares  its  structure  to  that  of  the  supra- 
renal capsules  of  the  foetus ; and  Montgomery  speaks  of  it  as  “ obviously 
and  strikingly  glandular.”  Corresponding  with  its  situation  externally, 


CORPUS  LUTEUM. 


61 


there  is  observable  a distinct  cicatrix  on  the  surface  of  the  ovary,  indi- 
cating the  spot  through  which  the  fluid  contained  in  the  Graafian  vesicle 
has  escaped  into  the  fallopian  tube.  The  aperture  has,  in  some  rare 
instances,  been  found  still  pervious,  when  the  conception  was  very  recent. 

The  corpus  luteum  will  present  different  appearances  according  to  the 
length  of  time  that  has  elapsed  since  impregnation.  In  the  early  weeks, 
that  portion  of  peritoneum  which  covers  it  projects  considerably  beyond 
the  surrounding  surface,  and  minute  vessels  are  seen  ramifying  over  it, 
Plate  XII,  fig.  38.  On  dividing  it,  the  central  cavity  is  clearly  distinguish- 
able, of  a tolerably  regular,  circular  figure,  around  which  is  deposited  the 
peculiar  substance  that  forms  its  principal,  essential  constituent — yellowish, 
and  possessing  numerous  thread-like  vessels  ramifying  through  it,  fig.  39. 
As  gestation  advances,  the  regularity  of  the  central  cavity  is  destroyed, 
figs.  40,  and  41 ; it  diminishes  in  size ; the  newly-secreted  yellow  matter 
becomes  plicated  and  absorbed,  till  at  last  the  walls  of  the  cyst,  gradually 
collapsing,  are  brought  into  close  contact,  and  a radiated  or  star-shaped 
series  of  lines  is  all  that  remains  of  the  former  cavity,  fig.  43.  During  this 
process,  both  the  vascularity  and  external  projection  are  day  by  day 
decreasing,  and  the  ovary  is  being  restored  to  its  former  volume  and 
appearance. 

The  length  of  time  during  which  the  corpus  luteum  continues  visible,  is 
not  exactly  ascertained,  and  probably  it  varies  considerably  according  to 
circumstances.  Montgomery  has  found  the  central  cavity  existing  in  the 
sixth  month  from  impregnation ; and  the  corpus  luteum  distinguishable  at 
the  end  of  five  months  from  mature  delivery,  but  never  beyond  that  time. 
From  the  observations  of  Dr.  Paterson,  indeed,  (Edin.  Med.  Journal,  Jan., 
1840,)  it  would  appear  that  positive  evidence  of  the  existence  of  this  body 
is  rarely  met  with,  even  three  or  four  months  after  labour ; so  that  the 
common  idea  that  this  is  a permanent  structure,  and  that  an  examination 
of  the  ovaries  after  death  will  enable  us  to  tell  the  exact  number  of  chil- 
dren which  any  woman  has  borne,  from  the  number  of  corpora  lutea 
existing  in  her  ovaries,  is  quite  erroneous. 

The  formation  of  this  body  is  explained  in  the  following  manner.  It 
has  been  demonstrated  that  the  Graafian  vesicle  possesses  two  membranes, 
one  adhering  to  the  substance  of  the  ovary,  the  other  enclosing  the  fluid 
in  which  the  ovule  of  Baer  floats.  When  a fruitful  connexion  takes  place, 
a great  determination  of  blood  is  made  to  that  ovary  which  supplies  the 
germ.  The  gland  becomes  larger,  rounder,  and  more  vascular,  than  the 
other ; to  the  touch  it  feels  fuller  and  softer.  But  the  vascularity  is  con- 
fined to  one  spot, — the  neighbourhood  of  the  corpus  luteum;  and  the 
increased  size  and  softness  result  not  so  much  from  an  alteration  in  the 
structure  of  the  whole  organ,  as  from  the  quantity  of  lymph  and  fluid 


62 


CORPUS  LUTEUM. 


blood  deposited  between  the  membranes  of  the  vesicle,  which  is  converted 
into  the  characteristic  yellow  gland-like  mass.*  This  effusion  causes  the 
vesicle  to  be  thrown  prominently  out  towards  the  peritoneal  surface ; the 
attenuated  coats  burst,  or  rather  an  opening  is  formed  by  absorption,  and 
the  fluid  previously  contained  within  them  passes  into  the  tube. 

False  Corpora  Lutea.  The  remark  of  Haller,  that  “ conception  never 
happens  without  the  production  of  a corpus  luteum ,”  has,  I believe,  never 
been  disputed ; but  his  other  proposition,  that  “ the  corpus  luteum  is  never 
found  in  virgin  animals , hut  is  the  effect  of  impregnation  alone  f has  been 
canvassed  very  extensively.  Some  physiologists  have  supposed  that  true 
corpora  lutea,  or  bodies  analogous  in  appearance  to  them,  can  be  formed 
in  the  ovaries  of  virgins;  while  others  have  expressed  themselves  so 
vaguely  on  the  subject,  as  to  leave  their  opinions  in  great  doubt.  The 
possibility  of  such  an  occurrence  is  a question  of  first-rate  importance  in 
many  medico-legal  investigations ; and  consequently,  it  is  incumbent  on 
every  one  who  touches  upon  this  subject  to  endeavour  to  put  it  in  a clear 
light. 

It  is  perfectly  true  that  spots  of  various  size,  shape,  colour,  and  consist- 
ence, are  met  with  in  the  virgin  ovary  of  all  animals,  differing  essentially 
from  the  surrounding  tissue ; but  it  is  equally  true  that  in  structure  they 
are  very  unlike  that  new  product,  the  result  of  impregnation ; and  with 
care  the  one  may  always  be  distinguished  from  the  other.  The  real  corpus 
luteum , in  the  early  weeks  after  conception,  possesses  a tolerably  regular 
circular  cavity,  sometimes  unoccupied,  at  others  filled  with  the  blood 
which  was  extravasated  at  the  time  when  the  coats  of  the  vesicle  gave 
way — at  the  moment,  indeed,  of  impregnation.  It  is  vascular,  and  its 
vascularity  may  be  shown  by  injection.  Its  two  coats  may  be  distinctly 
traced,  and  the  buff-coloured,  lymphy  deposite,  in  which  newly-formed 
vessels  ramify,  may  be  observed  between  them.  One  only  is  ever 
found  at  the  same  time  except  the  woman  had  conceived  of  twins,  or  had 
aborted  very  lately,  before  the  last  impregnation.  The  ovary  on  its 
external  surface,  above  the  spot  where  the  body  is  situated  within,  is 
vascular  and  more  prominent  than  at  the  other  parts,  fig.  38.  There  is 
a cicatrix  very  evident  at  the  same  point.  In  the  more  advanced  stage, 
the  central  cavity  is  contracted,  and  at  length  becomes  destroyed,  and  in 
its  place  is  seen  the  radiated  or  stellated  lines  already  mentioned,  which 
is  then  its  best  distinguishing  mark,  fig.  43.  The  luteum  itself  diminishes 
in  size  in  proportion  to  the  distance  of  time  from  conception. 

* Professor  Baer,  De  Ovi  Mammalium  et  Hominis  Genesi,  thinks  that  the  corpus  luteum  is 
produced  by  a thickening  of  the  inner  membrane  of  the  Graafian  vesicle ; and  Dr.  R.  Lee,  Med. 
Chirurg.  Trans.,  vol.  xxii.,  that  it  is  formed  outside  of  both  the  membranes.  My  own  opinion 
coincides  with  that  of  Drs.  Montgomery  and  Paterson. 


PI.  XII. 


<.P ■in&lctz*'  t j' 


\ * 


OVARIES. 


63 


On  the  contrary,  the  spurious , false , or  virgin  corpora  lutea , as  they 
have  been  incorrectly  termed,  are  of  various  shapes,  sometimes  triangular, 
at  others  square,  offering  no  regular  or  definite  figure,  fig.  42.  They  have 
no  vessels  in  their  substance,  and  consequently  cannot  be  injected,  fig.  44. 
Although  they  possess  two  coats,  they  are  entirely  destitute  of  the  inter- 
stitial, lymphy  deposite.  Their  texture  is  often  so  wanting  in  firmness,  as 
to  be  easily  broken  down.  Several  are  frequently  found  in  both  ovaries 
at  the  same  time.  The  peritoneum  covering  them  does  not  present  either 
prominence,  or  any  appearance  of  vascularity,  and  the  external  cicatrix 
is  seldom  met  with.  They  never  contain  the  perfectly-regular  central 
cavity,  nor  the  stelliform,  or  radiated  white  lines,  which  result  from  the 
closing  of  the  cavity.* 

In  advanced  lifej  the  ovaries  become  shrivelled,  corrugated  on  their 
surface,  firmer  in  their  texture,  and  often  contain  empty  collapsed  cysts, 
with  thickened,  opake  coats,  so  strong  that  they  can  be  turned  out  of  their 
bed  entire.  These  have  been  mistaken  for,  and  described  as,  corpora 
lutea;  but  after  the  account  already  given,  it  must  be  evident  that  such  is 
not  the  case.  There  is  little  doubt  that  they  are  Graafian  vesicles  altered 
by  age. 

That  the  ovarium  supplies  whatever  the  female  provides  towards  the 
formation  of  the  new  being,  is  proved  by  spaying  animals,  an  operation 
which  consists  in  taking  away  the  ovaries.  If  one  ovary  only  is  removed 
from  a multiparient  animal,  she  becomes  less  fruitful.  Hunter,  after  having 
deprived  a sow  of  one,  found  that  she  furrowed  six  less  than  another 
animal  of  the  same  age.  But  when  both  these  bodies  are  removed,  the 
subject  has  no  longer  any  desire  for  copulation,  loses  the  characteristics 


* The  drawings  in  Plate  XII.  are  copied  from  Montgomery’s  excellent  work  on  the  Signs 
and  Symptoms  of  Pregnancy,  and  are  of  the  natural  size.  Figs.  37,  38,  39,  are  taken  from 
the  ovaries  of  a woman  who  died  when  three  months  pregnant.  Fig.  37,  shows  the  appearance 
of  that  which  had  not  contributed  to  conception;  fig.  38,  the  external  surface  of  the  one 
which  had  furnished  the  germ,  and  which  is  enlarged  by  containing  the  corpus  luteum.  The 
vascularity  of  that  portion  surmounting  the  corpus  luteum  is  beautifully  displayed.  In  fig.  39, 
the  same  ovary  is  opened,  and  shows  its  internal  structure,  the  lymph  effused  between  the  coats, 
its  high  vascularity,  and  its  central  cavity,  which  had  previously  contained  the  fluid.  Fig.  40 
is  the  corpus  luteum  in  the  fourth  month  opened,  showing  the  vessels  running  through  its 
substance,  and  the  central  cavity  unusually  large  for  that  period  of  gestation.  Fig.  41,  the 
appearance  in  the  sixth  month,  the  corpus  luteum  still  retaining  its  central  cavity,  which  is 
unusual  at  so  late  a period.  Fig.  43,  the  ovary  of  a woman  who  died  sixteen  days  after  mature 
delivery,  exhibiting  the  corpus  luteum  with  its  stellated  central  white  line,  and  a few  small 
vessels  in  its  structure.  Fig.  42,  an  ovary  opened,  containing  spurious  or  virgin  corpora  lutea, 
which  possess  neither  the  appearance  of  a separated  double  membrane,  nor  stellated  lines,  nor 
any  vessels  in  their  structure.  Fig.  44  is  also  an  ovary  containing  spurious  corpora  lutea.  It 
was  injected  with  care,  but  none  of  the  colouring  matter  entered  the  spurious  products,  which 
were  destitute  of  vessels. 


64 


FALL  OPT  AN  TUBES. 


of  her  sex,  and  assumes  more  or  less  those  of  the  male.  This  is  remarked 
in  all  animals,  but  is  particularly  observable  in  the  feathered  tribes.  If 
the  ovaries  be  removed  from  a common  domestic  hen,  she  soon  becomes 
decked  with  somewhat  of  the  cock’s  plumage,  her  voice  is  changed,  and 
instead  of  her  usual  cackle,  she  utters  an  imperfect  crow.  The  female  of 
the  human  subject  ceases  to  menstruate ; long  straggling  hairs  grow  upon 
the  chin ; the  breasts  become  flabby,  being  deprived  of  part  both  of  their 
fat  and  glandular  structure ; the  skin  loses  its  soft  smoothness  ; the  voice 
becomes  harsh  and  discordant;  and  the  individual  might  easily  be  mis- 
taken for  a male.  Nor  are  the  moral  less  influenced  than  the  physical 
properties  : sexual  feelings  are  destroyed,  and  the  delicacy  of  the  female 
character  disappears.  This  change  was  strictly  exemplified  in  Mr.  Pott’s 
celebrated  ease,  where  both  ovaries  were  removed  in  an  operation  for 
hernia.  Similar  results,  indeed,  take  place,  as  are  observed  after  castia- 
tion  of  the  male:  so  that  to  the  presence  of  these  little  glands  the  female 
is  as  much  indebted  for  the  distinctive  physical  marks  and  moral  attri- 
butes of  her  sex,  as  the  male  is  to  the  possession  of  the  testes. 

Although  I have  followed  the  ordinary  usage  in  describing  the  ovaries 
as  appendages  to  the  uterus,  the  uterus  ought  in  truth  to  be  considered  as 
an  appendage  to  them  ; in  the  same  way  as  the  penis  may  be  considered 
an  appendage  to  the  testes.  For  they  are  the  most  essential  organs  m 
the  function  of  generation.  The  uterus  may  be  diseased  to  a great 
extent,  and  yet  the  woman  may  be  fruitful ; but  if  both  these  glands  are 
much  altered  in  structure,  barrenness  necessarily  ensues.  An  ovary, 
indeed,  or  something  analogous  to  it,  is  found  throughout  the  whole  of  the 

sexual  genera  of  both  animals  and  plants. 

Running  along  the  upper  edge  of  each  broad  ligament  there  is  a per- 
vious canal,  having  two  open  extremities— one  end  communicating  with 
the  uterine,  the  other  with  the  peritoneal  cavities : to  these  the  name  ol 
Fallopian  tubes  has  been  given,  after  their  first  describer.  They  are 
about  four  inches  in  length;  they  are  covered  externally  by  the  peri- 
toneum : possess  a middle  coat  of  muscular  fibres,  which  run  longitudi- 
nally, transversely,  and  obliquely,  and  an  internal  mucous  coat,  a con- 
tinuation of  the  mucous  membrane  lining  the  uterus.  At  the  abdomina 
extremity  they  are  fringed,  Plate  XI.  fig.  33,  (h. ,-)  XIII.  fig.  45,  (o.  o.;) 
XIII.  fig-  46,  ( f f.)  and  float  loose  and  unconnected  ; this  part  ol  the  tube 
is  called  the  fimbriated  extremity,  and  in  old  works,  from  its  office,  the 
morsus  Diaboli.  The  mucous  membrane  which  lines  the  tube  is  continued 
to  the  fimbria,  and  it  is  the  only  instance  in  the  body  where  a mucous 
and  a serous  membrane  join  by  continuation  of  structure— the  only 
example  of  a mucous  membrane  terminating  in  a shut  cavity. 

It  is  through  this  tube  that  the  ovum,  after  impregnation,  passes  into 


ROUND  LIGAMENTS. 


65 


the  uterine  cavity ; and  the  mode  in  which  it  is  affected  is  supposed  to  be 
the  following.  By  its  own  inherent  muscular  power,  the  Fallopian 
tube  under  the  venereal  orgasm,  erects  itself  somewhat  like  a snake 
raising  its  crest.  By  the  same  inherent  muscular  power  it  directs  itself 
to  the  ovarium,  it  widely  spreads  its  fimbriae,  expands  itself  upon  the 
external  surface  of  the  gland,  closely  embraces  it,  and  squeezes  from  it 
the  contents  of  one  or  more  of  the  vesicles  of  De  Graaf.  Plate  XI.  fig. 
33,  (z.)  Freighted  with  their  living  burden,  the  fimbriae  approximate  each 
other,  close  the  orifice,  before  wide  spreading  and  patulous ; and  a motion 
somewhat  like  the  peristaltic  action  of  the  intestinal  canal  is  then  set  up 
in  the  tube,  by  which  means  the  ovum,  now  impregnated,  traverses  the 
length  of  the  canal  until  it  drops  into  the  uterine  cavity.  We  have  both 
negative  and  positive  proof  of  the  strongest  kind,  that  the  ovum  passes 
through  the  Fallopian  tube  before  it  arrives  at  the  uterus — negative , 
because  there  is  no  other  canal  through  which  it  can  be  conveyed,  there 
being  no  direct  communication  between  the  ovarium  and  the  uterus : nega- 
live,  also,  because,  if  we  cut  away  a portion  of  the  Fallopian  tube  from 
each  side,  so  as  to  destroy  the  continuity  of  the  canal,  we  prevent  con- 
ception, although  we  do  not  take  away  the  desire  for  copulation ; — but 
farther,  we  have  'positive  proof  because  an  impregnated  ovum  has  been 
frequently  found  within  the  tube ; it  has  been  arrested  in  its  transit,  formed 
a bed  for  itself  within  the  dilated  canal,  and  there  grown ; constituting  a 
species  of  that  disease  termed  extra-iiterine  conception.  Thus  we  cannot 
for  a moment  doubt  that  the  ovum  travels  along  the  Failopian  tube  to 
gain  the  uterine  cavity.  The  sensation  communicated  to  the  finger  by 
squeezing  the  tube  is  very  much  like  that  of  the  spermatic  cord.  It  is 
hard,  firm,  and  wiry.  In  its  office  it  may  be  assimilated  to  the  vas 
deferens  of  the  male. 

The  round  ligaments  are  two  small  circular  cords,  which,  arising  from 
the  angle  of  the  uterus  at  its  sides,  anterior  to,  and  rather  below  the 
Fallopian  tubes,  run  between  the  duplicatures  of  the  peritoneum,  con- 
stituting the  broad  ligaments,  until  they  arrive  at  the  sides  of  the 
pelvis.  They  then  leave  the  broad  ligaments,  and,  turning  forwards,  take 
their  course  round  just  below  the  brim,  eventually  pass  out  at  the  ring  of 
the  external  oblique  muscle,  and  are  lost  in  the  groin  and  parts  adjacent. 
They  consist  of  a congeries  of  blood-vessels,  nerves,  and  absorbents ; and 
by  them  a communication  is  kept  up  between  the  uterus  within  the  pelvis 
and  the  structures  on  the  outside.  It  is  in  consequence  of  this  direct 
communication,  that,  in  some  of  the  malignant  diseases  of  the  uterus,  the 
glands  in  the  groin  take  upon  themselves  unhealthy  action,  and  become 
enlarged,  indurated,  and  occasionally  ulcerated. 

The  round  ligaments  are  figured  in  Plate  XI.  fig.  33  (/ /,)  also  one  in 
9 


66 


SECTION  OF  THE  PELVIS. 


Plate  XIII.  fig.  45  (p,)  and  particularly  well  shown  in  Plate  XIII.  fig. 
46  (z  z*,)  where  their  origin,  course,  and  escape  through  the  ring  may  be 
clearly  traced. 

Plate  XI.  fig.  33,  shows  the  back  face  of  the  vagina,  the  uterus,  and  its 
appendages.  On  the  left  side,  the  peritoneum  is  dissected  off  the  body 
of  the  uterus,  to  display  the  round  ligament  more  fully.  The  fimbriated 
extremity  of  the  left  Fallopian  tube  is  spread  upon  and  embracing  the 
ovary  of  that  side,  as  happens  during  conception,  (a)  the  fundus  uteri, 
( b ) its  body,  (c)  the  neck,  ( d ) the  mouth,  ( e e)  the  broad  ligaments,  ( ff ) 
the  round  ligaments,  (gg)  the  Fallopian  tubes,  (h)  the  fimbriated  extremity 
of  the  right  side,  (it)  the  ovaries,  (A:)  the  vagina  split  up,  to  show  the 
rugse  on  its  posterior  surface. 

Plate  XIII.  fig.  45,  represents  the  left  section  of  the  female  pelvis,  drawn 
from  a very  accurate  German  model  in  my  collection,  (a)  the  fourth 
lumbar  vertebra,  ( b ) the  rectum,  (c)  the  left  iliac  fossa,  ( d ) the  rectus 
abdominus  muscle,  springing  from  ( e ) the  symphysis  pubis,  (/)  the  mons 
venerus,  (g)  the  clitoris,  (Zz)  the  left  nympha,  (z)  the  left  labium  externum, 
(k)  the  fundus  uteri,  (Z  l ) the  ovaries  brought  upwards,  (m)  the  posterior 
surface  of  the  right  broad  ligament,  (n)  the  right  Fallopian  tube  turned 
downwards,  (oo)  the  fimbriated  extremities  of  the  tubes,  ( p ) the  right 
round  ligament — the  dotted  line  crosses  the  fundus  of  the  bladder,  ( q ) the 
os  uteri,  (r)  the  vagina,  (s)  the  point  of  the  coxyx,  (t)  the  sphincter  ani, 
( v ) the  sphincter  of  the  bladder,  (w)  the  urethra — the  dotted  line  crosses 
the  perineum,  (x)  the  meatus  urinarius. 

Plate  XIII.  fig.  46,  gives  a good  view  of  the  flooring  of  the  pelvis 
looking  into  it  from  the  abdomen ; it  is  taken  from  a cast  also  in  my 
collection,  modelled  by  the  late  Mr.  Joshua  Brookes,  (a)  the  mons 
vcxrc lis,  (&)  the  bladder,  (c)  the  fundus  uteri,  (d)  the  rectum,  (ee)  the 
Fallopian  tubes,  (ff)  their  fimbriated  extremities,  (gg)  the  ovaries 
brought  upwards  into  view,  (h  h)  the  posterior  processes  of  the  broad 
ligaments,  (z  z)  the  round  ligaments  running  forwards  to  escape  out  of  the 
pelvis  at  the  ring,  (k)  the  ccecum  with  its  appendix  vermiformis,  (/)  the 
small  intestines,  (m)  the  body  of  one  of  the  lumbar  vertebras. 

Plate  XIV.  fig.  47,  delineates  the  arteries  of  the  uterus;  it  is  copied 
from  one  of  Tiedemann’s  beautiful  engravings.  The  patient  from  whom 
the  drawing  was  taken  died  six  days  after  mature  delivery,  (a  a)  the 
kidneys,  (b  b)  the  ureters,  (c)  the  uterus,  about  the  comparative  size  it  is 
usually  found  six  days  after  labour ; it  is  turned  forwards  over  the  pubes, 
so  that  its  posterior  face  is  brought  into  view ; (d  d)  the  broad  ligaments, 
(e  e)  the  ovaries,  (ff)  the  Fallopian  tubes,  (g)  the  rectum  cut,  ( h ) the 
aorta,  (z)  the  superior  mesenteric  artery  divided,  (k)  the  inferior  do.,  (ZZ) 
the  renal,  (mm)  the  common  iliacs,  (nn)  the  external  do.,  (oo)  the 


Sl?9  £rLa32'  sJjr  lith. 


PELVIC  NERVES. 


67 


internal  do.,  (pp)  the  uterine  arising  from  the  internal  iliacs,  (qq)  the 
gluteal,  (rr)  the  obturators,  (s  s)  the  internal  pudic,  {t  t)  the  ischiatic, 
( uu ) the  lateral  sacral,  (ww)  the  circumflexa  ilii,  ( x ) the  sacra  media, 
(yy)  the  spermatics,  arising  from  the  aorta  just  below  the  renal;  in  this 
instance,  as  is  most  common,  by  two  distinct  branches. 

The  nerves  particularly  requiring  our  attention  run  in  ffve  divisions. 
1st.  There  is  a large  cutaneous  branch,  which  rises  from  the  second  and 
third  lumbar  nerves,  traverses  the  iliac  and  psoas  muscles,  and  following 
the  spine  of  the  ilium  is  expended  on  the  integuments  of  the  outer  part  of 
the  thigh.  This  nerve  is  too  high  to  suffer  under  labour,  but  it  is  liable  to 
pressure  during  the  last  few  weeks  of  pregnancy;  the  consequence  of 
which  is  numbness  in  the  track  of  its  distribution.  2nd.  The  anterior 
crural  nerve, — one  of  great  magnitude, — takes  its  origin  from  the  second, 
third,  and  fourth  lumbar  nerves,  passes  over  the  pelvic  brim  outside  the 
femoral  artery,  to  be  distributed  principally  on  the  rectus  femoris,  and 
other  flexors  of  the  thigh.  It  is  also  out  of  the  way  of  pressure  under 
labour,  but  like  the  cutaneous  branches,  may  suffer  towards  the  close  of 
gestation,  to  such  an  extent  as  to  produce  cramp  on  the  inner  and  fore 
parts  of  the  thigh.  3rd.  The  obturator,  which  rises  from  the  third  and 
fourth  lumbar  nerves,  run  round  below  the  brim  of  the  pelvis  and  passes 
out  at  the  upper  part  of  the  obturator  foramen.  This  is  chiefly  distributed 
to  the  abductor  muscles  of  the  thigh,  and  pressure  on  it  sometimes  occa- 
sions cramps  on  the  inside  of  the  thigh,  at  the  commencement  of  labour, 
while  the  child’s  head  is  entering  the  brim.  4th.  The  great  sciatic,  the 
largest  nerve  in  the  body,  is  formed  of  the  fourth  and  fifth  lumbar,  and 
the  first,  second,  and  third  sacral  nerves.  It  lies  over  the  sacro-iliac 
symphysis,  and  passes  out  of  the  pelvis  by  the  side  of  the  pyriform 
muscle,  through  the  large  sacro-sciatic  foramen,  to  be  distributed  to  the 
posterior  part  of  the  thigh,  and  to  supply  the  leg  and  foot.  This  nerve, 
situated  at  the  back  part  of  the  pelvic  cavity,  and  passing  directly  through 
it,  is  particularly  exposed  to  pressure  during  child-birth;  and  it  is  not 
surprising  that  much  inconvenience  should  result.  Violent  cramps  in  the 
extensor  muscles  of  the  thigh,  and  especially  in  the  calf  and  plantar  sole, 
are  almost  universally  attendant  on  lingering  labours,  and  often,  also,  on 
those  of  ordinary  duration,  during  the  time  when  the  head  is  fully  occupy- 
ing the  pelvic  cavity.  Such  muscular  spasms  add  much  to  the  agony 
endured ; they  may  sometimes  be  mitigated  by  pressure  and  hard  friction 
over  the  part  in  pain.  5th.  The  fourth  sacral  is  entirely  expended  on  the 
parts  within  the  pelvis  and  about  the  anus.  The  fifth  is  sometimes 
wanting,  and  is  always  very  small.  The  pudic  nerve  which  supplies  the 
clitoris  and  other  external  organs  is  derived  principally  from  the  third 
sacral. 


68 


PELVIC  NERVES. 


Thus,  when  first  the  uterus  subsides,  preparatory  to  its  taking  on 
expulsive  action,  the  cutaneous  and  crural  nerves  suffer,  causing  numb- 
ness and  pain  in  the  fore  and  outer  part  of  the  thigh ; when  the  head  is 
passing  through  the  brim  the  obturator  may  be  pressed  on,  producing 
cramps  on  the  inside  of  the  thigh:  when  labour  is  well  advanced,  the 
sciatic  can  scarcely  escape  pressure ; and  more  or  less  of  cramp  at  the 
back  part  of  the  thigh,  the  calf  of  the  leg,  and  sole  of  the  foot,  is  the 
consequence.  Occasionally,  indeed,  lameness  and  partial  paralysis  con- 
tinue for  some  time  after.  The  varicose  state  of  the  veins,  and  anasar- 
cous  swellings  of  the  lower  extremities,  so  common  during  pregnancy, 
also  originate  from  pressure,  and  mostly  disappear,  or  are  much  re- 
lieved, in  a few  days  after  the  termination  of  the  labour. 

Plate  XIV.  fig.  48,  from  Moreau’s  work,  faithfully  describes  the  course 
and  distribution  of  the  principal  pelvic  nerves ; it  is  drawn  from  the  body 
of  a woman  who  died  four  days  after  labour.  The  left  side  of  the  pelvis 
is  cut  away,  the  division  being  made  at  the  saero-iliac  symphysis,  poste- 
riorly, and  at  the  ramus  of  the  pubes  in  front,  just  at  its  outer  extremity, 
before  it  divides  into  the  two  branches,  horizontal  and  descending.  The 
bladder  collapsed  is  seen  behind  the  pubes,  the  vagina  and  rectum  are 
also  well  displayed,  as  is  the  uterus,  large,  from  having  so  recently  ex- 
pelled a foetus.  The  left  ovary  is  drawn  up,  and  the  fallopian  tubes  fore- 
shortened, to  give  a view  of  the  spermatic  vein  ( a ,)  and  the  spermatic 
artery  (b ;)  (c)  directs  to  the  vena  cava,  ( d ) the  aorta ; (e  e)  cut  portions 
of  the  inferior  mesenteric  nerves,  branches  of  the  great  sympathetic;  (fg) 
the  fourth  and  fifth  lumbar  ganglia ; (h  i k)  the  first,  second,  and  third 
sacral;  (m  m m)  the  sacral  nerves  cut  which  are  to  form  the  great 
sciatic;  (n)  a branch  supplying  the  lower  part  of  the  rectum,  which 
rises  from  the  fourth  sacral.  Immediately  below  the  bifurcation  of  the 
aorta,  lying  over  the  sacral  promontory,  a large  plexus  of  nervous 
filaments  is  seen,  which  is  called  the  superior  hypogastric,  or  common 
uterine  plexus ; this  is  formed  by  the  continuation  of  the  inferior  mesenteric 
nerve,  and  by  branches  from  the  lumbar  ganglia ; it  chiefly  supplies  the 
uterus.  On  the  side  of  the  vagina,  rather  above  its  centre,  there  is  visible 
another  extensive  plexus  of  nervous  threads,  spread  out  into  a large  number 
of  irregular  meshes ; this  is  also  formed  from  branches  sent  off  from  the 
inferior  mesenteric,  and  others  from  the  lumbar  and  sacral  ganglia,  and 
from  the  sacral  nerves,  and  supplies  the  upper  part  of  the  vagina  and  the 
lower  portion  of  the  uterus;  this  is  the  inferior  hypogastric  plexus. 
Branches  arise  from  the  lower  sacral  nerves  ( m m,)  to  be  distributed  on 
the  bladder,  and  lower  part  of  the  vagina,  the  vesical  and  vaginal  nerves. 
Behind  these  nerves,  and  the  inferior  hypogastric  plexus,  the  uterine  artery 
may  be  observed  running  up  the  vagina,  and  giving  off  transverse  branches 


ANALOGY,  GENITAL  ORGANS  IN  TWO  SEXES.  69 


to  that  organ.  The  pudic  nerves  are  not  shown  here.  It  is  evident  that, 
since  they  emerge  from  the  pelvis,  and  re-enter  it,  the  pudic  nerve  on  the 
side  opened  must  be  destroyed,  when  the  pelvis  is  divided  as  this  plate 
represents. 

The  muscles  within  the  'pelvis  deserve  notice ; for,  by  being  pressed  on 
during  the  escape  of  the  child’s  head,  they  are  sometimes  strained,  and 
pain  is  experienced  in  moving  the  thigh,  and  in  evacuating  the  rectum,  for 
some  days  subsequent  to  labour.  The  levator  ani , one  on  each  side,  of 
the  shape  of  a fan,  rises  from  the  pubes  just  below  the  brim,  the  aponeu- 
rosis covering  the  obturator  internus,  and  the  spinous  process  of  the  ischium, 
passes  down  by  the  side  of  the  vagina,  and  is  inserted  into  the  sphincter 
ani,  as  seen  in  Plate  XIV.  fig.  48.  On  dissecting  away  these  fibres,  we 
observe  the  obturator  internus;  which,  taking  its  origin  from  the  inner 
surface  of  the  obturator  ligament,  and  a portion  of  both  the  pubes  and 
ischium  in  the  neighbourhood  of  the  foramen,  sends  off  a tendon  that, 
running  round  the  ischium  like  a pulley,  passes  out  of  the  pelvis  through 
the  small  sacro-sciatic  foramen,  and  is  inserted  into  the  fossa  trochanterica 
at  the  root  of  the  trochanter  major.  The  pyriformis  rises  from  the  ante- 
rior surface  of  the  second,  third,  and  fourth  divisions  of  the  sacrum, 
escapes  from  the  pelvis  through  the  large  sacro-sciatic  foramen,  and  is 
also  inserted  into  the  fossa  trochanterica,  near  the  insertion  of  the  obtu- 
rator. The  coxygeus  springs  from  the  spinous  process  of  the  ischium,  and 
is  attached  to  the  side  of  the  coxyx  through  nearly  its  whole  extent.  The 
transversus  perinei  rises  from  the  side  of  the  tuber  ischii,  and  is  lost  upon 
the  sphincter  ani,  sphincter  vaginae,  and  the  structure  of  the  perineum 
itself. 

Analogy  between  the  genital  organs  in  the  two  sexes. — Although  the 
organs  of  generation  appear  to  be  widely  different  in  the  two  sexes,  and 
indeed  give  them  their  distinctive  characters ; yet  there  is  seen,  on  closely 
comparing  them,  a great  similarity,  not  only  in  function,  but  even  in  for- 
mation ; so  that  we  cannot  withhold  our  belief  that  they  have  both  been 
fashioned  on  a common  model.  The  resemblance  between  the  ovaria 
and  testes  in  office,  form,  organic  elements,  and  original  situation  is  most 
striking.  For  the  testes  lie  in  the  abdomen  until  about  seven  months  of 
foetal  life  are  passed,  and  they  are  both  supplied  by  blood-vessels  arising 
from  the  same  source,  and  following  the  same  track.  The  uterus  has 
been  likened  to  the  prostate ; and  it  certainly  bears  a great  similitude,  in 
its  position  at  least,  during  foetal  life.  The  vasa  deferentia  and  fallopian 
tubes  resemble  each  other  in  function,  and  construction.  The  clitoris  may 
be  likened  to  the  penis,  and  the  labia  to  the  scrotum.  In  many  instances 
the  confusion  arising  from  this  similitude  is  so  remarkable  that  it  is  diffi- 
cult to  decide,  particularly  in  infancy,  to  which  sex  the  individual  belongs. 


70  ANALOGY,  GENITAL  ORGANS  IN  TWO  SEXES. 


It  must  be  observed,  indeed,  that  the  earlier  the  time  chosen  for  making 
the  comparison,  the  stronger  will  the  resemblance  be.  The  clitoris  of  a 
foetus  of  three  months  is  as  large  as  the  penis  of  a male  at  the  same  age, 
and  in  a more  recent  period  of  intra-uterine  existence  the  distinction  of  the 
sex  is  by  no  means  perceptible. 


cK»(-9  p 


PI.  XIV. 


riV 


LIBRARY 

InE 

U N I V E.t\3 V \ Y Or  ILLINOIS 


OF  THE  GRAVID  UTERUS. 


Plates  XV.,  XVI.,  XVII.,  XVIII.,  XIX.,  XX.,  XXI. 

Contrast  between  the  unimpregnated  and  gravid  Uterus. — When  we 
compare  the  unimpregnated  with  the  gravid  uterus  at  the  end  of  gestation, 
we  should  be  inclined  to  doubt, — from  the  extraordinary  alteration  that 
has  taken  place  during  pregnancy — whether  in  reality  they  were  not  two 
perfectly  distinct  organs.  We  observe  an  amazing  difference,  indeed,  in 
every  essential  attribute,  particularly  inform,  size,  situation , texture,  power, 
and  contents. 

The  Form  has  undergone  great  change:  previously  to  impregnation  it 
is  somewhat  triangular,  or  like  a slightly  compressed  pear ; at  the  end  of 
gestation  it  is  of  an  egg  shape. 

The  alteration  in  size  is  most  remarkable ; the  virgin  uterus  measures 
not  more  than  three  inches  in  length,  and  two  in  breadth ; when  labour  is 
near  at  hand,  it  is  about  thirteen  inches  long,  and  eight  or  nine  across. 

The  unimpregnated  uterus  has  been  described  as  situated  within  the 
pelvis,  between  the  bladder  and  the  rectum,  sustained  in  its  position  by 
ligaments  passing  from  it  to  the  pelvic  and  lumbar  bones.  On  the  con- 
trary, the  gravid  uterus  has  become  an  abdominal  viscus ; it  fills  a large 
portion  of  that  cavity,  stretches  the  muscles  considerably,  and  is  supported 
by  the  parietes  in  front  and  at  the  sides,  and  by  the  pelvic  bones  below. 

The  texture  of  the  unimpregnated  uterus  is  close,  tough,  firm,  and  ine- 
lastic ; the  structure  of  the  organ  when  gravid  is  loose,  spongy,  and  dis- 
tensible, capable  of  being  drawn  out  to  a considerable  extent  between  the 
fingers  without  laceration  of  its  substance.  The  looseness  of  its  texture 
depends  chiefly  on  the  enormously  increased  size  which  its  vessels  have 
acquired  during  the  development  of  the  organ. 


72 


DECIDUOUS  MEMBRANE. 


The  unimpregnated  uterus  possesses  no  power  but  that  of  secreting,  and 
assisting  in  the  function  of  conception ; the  gravid  womb  possesses  the 
power  of  affording  lodgment  to  the  embryo,  nourishing,  and  eventually 
expelling  it. 

The  section  of  the  unimpregnated  uterus  displays  an  unoccupied  cavity, 
communicating  by  an  open  mouth  with  the  vagina  below,  having,  there- 
fore, properly  speaking,  no  contents  ; while  the  gravid  contains  the  mem- 
brana  decidua , and  the  ovum  ; which  latter  consists  of  the  chorion , the 
amnion , the  liquor  amnii,  the  'placenta , the  funis  umbilicalis,  th q foetus, 
and,  in  an  early  stage  of  pregnancy,  the  vesicula  umbilicalis. 

On  opening  the  gravid  uterus,  besides  the  spongy  character  of  its  struc- 
ture just  adverted  to,  and  the  large  size  of  its  vessels,  (which  have  acquired 
such  a magnitude,  that  the  veins  have  the  term  sinuses  applied  to  them,) 
its  thickness  must  necessarily  become  an  object  of  observation.  This 
varies  considerably  in  different  individuals;  the  substance  is  generally 
rather  thicker  than  in  the  unimpregnated  state  ; and  in  all  instances  the 
fibres  are  more  apparent.  Having  completely  divided  the  parietes,  we 
cut  down  upon  the  deciduous  membrane. 

Membrana  Decidua  or  Caduca.* — This  is  an  opaque  membrane,  lining 
the  entire  cavity,  and  in  contact  with  the  internal  surface  of  the  uterus 
throughout  its  whole  extent.  It  is  divisible  into  two  layers,  both  together 
being  not  thicker  than  the  nail,  and  is  flocculent  on  that  face  which  is 
attached  to  the  uterus ; smooth  and  plane  on  the  one  next  the  ovum ; — so 
glossy,  indeed,  that  it  might  be  supposed  to  possess  serous  properties.  But 
the  most  patient  investigators  have  not  been  able  to  discover  any  forma- 
tion in  the  decidua  analogous  to  serous  structure.  It  is  highly  vascular, 
is  supplied  with  blood  from  the  uterine  vessels,  and  has  a tenacity  between 
true  and  false  membrane.  In  the  early  period  of  pregnancy,  the  two 
lavers  are  separated  from  each  other,  especially  towards  the  fundus  uteri, 
by  a quantity  of  red  coloured  fluid,  partly  serous,  and  partly  half  coagu- 
lated, to  which  Breschet,  who  designates  it  sero-albuminous,  has  given 

* These  names  were  given  to  the  membrane  by  Dr.  Hunter  (who  was  the  first  to  demon- 
strate its  two  lamince)  in  consequence  of  its  being  shed  from  the  uterus  after  labour,  with 
other  discharges.  He  also  called  the  outer  layer  the  decidua  vera  and  the  inner  decidua 
rejlexa.  I prefer  the  terms  employed  by  Dr.  R.  Lee,  decidua  uteri  and  decidua  ovuli;  because 
their  adoption  merely  describes  the  situation  and  connexion  of  the  two  laminae,  and  does  not 
involve  any  theory  as  to  the  formation  of  the  inner  layer,  about  which  there  is  still  conside- 
rable doubt.  Of  late  it  has  been  described  by  Chaussier  under  the  title  epichorion , from  «t/, 
above,  and  xvpiov,  the  external  ovular  membrane;  by  Dutrochet  epione , from  rrt,  and  uov  the 
ovum;  by  Breschet perione,  from  n-tpi  around,  and  aov : and  by  Velpeau  anhiste , from  a priv; 
and  irroc,  a web.  Velpeau  uses  this  term  to  signify  an  inorganic  substance,  since  he  denies 
the  organization  of  the  membrane  at  any  period  of  pregnancy. 


DECIDUOUS  MEMBRAN  E. 


TS 

the  name  of  hydroperione .*  As  gestation  advances,  this  fluid  is  gradually 
absorbed,  and  the  two  laminae  come  into  close  contact  at  every  point, 
except  where  the  placenta  intervenes  between  them.  For  they  are 
described  as  splitting  at  the  edge  of  the  placenta ; and  while  one  layer 
passes  between  it  and  the  uterus,  the  other  traverses  the  foetal  face  of  the 
organ,  being  interposed  between  its  substance  and  the  chorion. 

The  deciduous  membrane  is  a product  of  the  uterus,  and  does  not  origi- 
nate in  the  ovum.  It  is  not  a constituent  part  of  the  ovum,  and  is  only 
connected  with,  and  subservient  to  the  embryo  as  an  uterine  formation, 
the  consequence  of  pregnancy.  This  is  proved  to  be  the  case  because,  in 
extra-uterine  gestation,  although  the  ovum  has  never  entered  the  uterus, 
this  membrane  is  invariably  formed  within  the  uterine  cavity.  It  is  fur- 
nished by  the  uterine  vessels,  and  its  secretion  commences  immediately 
upon  impregnation  taking  place ; so  that  even  before  the  ovum  can  be 
discovered  by  the'  naked  eye, — while  it  is  yet  traversing  the  Fallopian 
tube — the  rudiments  of  the  decidua  may  be  found  within  the  womb.  At 
first  it  consists  of  a tenacious  fluid ; and  by  degrees  it  assumes  the  charac- 
ter of  a perfect,  organized,  tender  membrane. 

Hunter  called  the  internal  layer  decidua  rejiexa,  from  the  supposition 
that  its  production  was  the  effect  of  the  following  process.  He  presumed 
that  on  the  impregnated  ovum  arriving  at  the  uterine  extremity  of  the 
Fallopian  tube,  it  meets  with  resistance  from  this  membrane,  lying  stretched 
across  the  mouth  of  the  tube ; that  in  its  descent  into  the  cavity,  it  carries 
the  membrane  before  it,  doubles  it  upon  itself,  and  thus  forms  two  layers 
from  the  original  single  one.  Other  physiologists  of  repute  have  also 
adopted  Hunter’s  ideas ; but  their  correctness  in  this  respect  is  very  doubt- 
ful; for  a prolongation  of  the  outer  membrane  has  been  frequently  observed 
passing  a little  way  into  each  Fallopian  tube,  which  could  not  be  the  case 
were  the  internal  merely  a duplicature  of  the  outer  layer.f 

Its  value  appears  to  be  principally,  if  not  entirely,  confined  to  the  first 
few  weeks  of  pregnancy ; it  would  seem  to  be  of  little  service  towards  the 
close. 

* The  two  layers  of  the  deciduous  membrane  are  well  shown  in  Plate  XV.  fig.  51.  This 
ovum  is  about  seven  weeks  old  : ( a f the  decidua  vera,  or  uteri;  (6)  decidua  rejiexa  or  ovuli;  (c) 
chorion  ; (d)  amnion;  (e)  funis  umbilicalis;  (/)  embryo;  (g)  prolongation  of  the  decidua  uteri 
into  the  neck  of  the  womb.  In  this  specimen,  the  inner  layer  of  the  decidua  forms  a shut 
sac,  and  there  is  no  appearance  of  any  prolongation  of  the  outer  layer  into  either  Fallopian 
tube,  nor  of  any  apertures  tallying  with  the  commencement  of  the  tubes.  Fig.  50,  shows 
the  flocculent  character  of  the  surface  of  the  membrane  in  contact  with  the  uterus.  Fig.  49, 
the  smooth  glossy  face  next  the  ovum.  This  piece  of  deciduous  membrane  was  taken  from 
an  oVum  of  later  date. 

t Granville,  “ Graphic  Illustrations  of  Abortion,”  considers  the  decidua  reflexa  as  an  ovular 
membrane,  and  denominates  it  “ the  cortical  membrane,”  “ cortex  ovi.” 

10 


74 


DECIDUOUS  MEMBRANE. 


It  is  subservient  both  to  the  nutrition  of  the  embryo,  and  to  the  preser- 
vation of  its  vitality ; and  thus,  before  the  elaboration  of  the  placenta,  it 
seems  to  perform  for  the  new  being,  functions  analogous  to  those  which, 
in  an  after  stage,  are  carried  on  by  the  placenta  itself. 

When  the  ovum  is  first  seen,  it  is  completely  surrounded  by  minute 
filamentous,  mossy  vessels,  as  with  an  efflorescence,  which  proceed  from 
the  chorion  and  embed  themselves  in  the  semi-fluid  deciduous  secretion; 
these  have  been  called  the  shaggy  chorion .#  As  it  continues  to  grow,  the 
chorion  and  amnion  increase  in  extent,  but  the  flocculent  vessels  do  not 
increase  in  the  same  proportion.  They  now  no  longer  surround  it  at  all 
points,  but  are  left,  as  it  were,  in  one  corner,  and  gradually  become  clus- 
tered together,  to  form  the  fleshy  placenta;  while  the  greater  part  of  the 
ovum  becomes  as  gradually  enveloped  by  the  thin  pellucid  membranes. 

Plate  XV.  fig.  52,  shows  the  filamentous  vessels  entirely  surrounding  the 
chorion.  Fig.  53  (aj  the  same  vessels  thicker  and  more  numerous  at 
this  point  than  at  any  other : they  are  being  collected,  by  degrees,  into  one 
mass,  for  the  formation  of  the  placenta ; (&,)  the  chorion  denuded  of  the 
shaggy  vessels.  Fig.  54  (a,)  the  pellucid  membranes  which  have  increased 
in  extent,  leaving  the  shaggy  vessels  collected  into  one  mass,  to  form  (h,)  the 
placenta;  (c,)  the  embryo  seen  through  the  membranes.  This  ovum  is 
about  eight  weeks  old,  and  is  the  most  perfect  specimen  of  so  early  a 
placenta  I have  yet  seen.  The  drawing  represents  the  appearance  of  the 
ovum  when  it  was  expelled,  distended  with  the  amnial  fluid. 

Plate  XVI.  fig.  56,  from  Hunter’s  splendid  work  on  the  gravid  uterus, 
displays  an  ovum  of  five  months  of  age  within  the  womb,  which  has  been 
laid  open;  the  vessels  ramifying  on  the  decidua  ovuli  are  well  delineated; 
and  the  gelatine  secreted  by  the  gladulxe  Nabothi  at  the  cervix  uteri  (a,) 
is  also  tolerably  distinctly  pictured.  One  coil  of  the  funis  is  seen  tw'isted 
round  the  neck,  and  another  round  the  left  ankle. 

As  gestation  advances,  the  deciduous  membrane  becomes  thinner  and 
less  tenacious ; and  at  the  full  period  of  pregnancy,  it  is  very  difficult  to 
separate  the  tw7o  layers  one  from  the  other. 

* Velpeau,  Carus,  Breschet,  and  other  physiologists,  think  that  these  villi  are  not  blood- 
vessels, because  they  cannot  detect  canals  in  them,  even  by  powerful  glasses ; and  Dr.  Mont- 
gomery, in  a paper  in  the  4th  volume  of  Dublin  Medical  and  Surgical  Journal,  says,  “They 
seem  to  be  merely  spongioles  and  to  act  as  suckers,  by  which  the  ovum  is  supported  until  its 
connexion  with  the  uterus  is  more  perfectly  accomplished  by  the  development  of  the  vessels 
of  the  placenta.”  I look  upon  them  as  blood-vessels.  They  are  very  similar  to  the  vascular 
tassels  attached  to  the  foetal  membranes  which  dip  into  the  cups  of  the  cotyledons  in  the  gravid 
uterus  of  the  cow  and  sheep,  and  which  in  those  animals  are  most  easily  injected  from  the 
umbilical  vessels.  They  are  evidently  for  the  purpose  of  nourishing  the  young  ovum.  Baillie 
(continuation  of  Hunter’s  description  of  the  gravid  uterus)  says,  probably  some  of  them  are 
lymphatics,  though  that  has  not  been  demonstrated. 


PIXY. 


LIBRARY 
Of  THE 

CN'JVERSIYY  OF  iLUN’OJC 


* 


C II  0 R I 0 N. — A MNIO  N. 


75 


Chorion. — Having  divided  the  decidua  in  our  dissection,  we  arrive  at  the 
external  membrane  of  the  ovum,  the  chorion  ; a thin,  glistening,  transparent 
membrane,  much  resembling  the  delicate  serous  tissues,  very  tough  for  its 
tenuity,  enveloping  and  affording  an  external  covering  to  the  whole  of  the 
ovum,  with  the  exception  of  the  placenta,  which  is  interposed  between  it 
and  the  uterus.  It  passes  on  the  foetal  face  of  the  placenta,  and  gives  a 
coat  to  that  surface  as  well  as  to  the  funis  umbilicalis. 

It  is  a constituent  part  of  the  ovum  from  the  remotest  period  of  concep- 
tion, because  in  extra-uterine  pregnancy  we  find  it,  not  in  the  uterus,  as 
the  deciduous  membrane  is,  but  enclosing  the  embryo  itself.  It  possesses 
no  blood-vessels  evident  to  the  naked  eye;  but  we  cannot  deny  its  vascu- 
larity, since  it  is  subject  to  disease,  and  in  many  of  the  mammalia  may  be 
readily  injected.  It  is  for  the  purpose  of  protecting  the  embryo  in  con- 
junction with  the  amnion,  and  of  assisting  to  form  both  a bag  for  contain- 
ing the  liquor  amnii,  and  also  a soft  wedge  by  which  the  structures 
during  labour,  may  be  dilated  with  the  least  possible  chance  of  injury. 

Amnion. — The  chorion  having  been  cut  through,  we  next  meet  with  the 
amnion,  another  very  thin,  transparent,  and  tough  membrane,  in  structure 
and  appearance  so  similar  to  the  chorion,  that  it  is  almost  impossible  to 
distinguish  the  one  from  the  other.  It  is  destitute  of  coloured  vessels,  but 
it,  too,  must  possess  vascularity ; because,  like  its  twin  sister,  it  becomes 
thickened  by  disease,  and  because  it  enjoys  in  an  eminent  degree  the  power 
of  secretion.  It  runs  in  contact  with  the  chorion  throughout  its  whole 
extent,  except  just  at  the  placental  extremity  of  the  funis  umbilicalis, 
where  these  membranes  are  separated ; and  to  this  formation  the  term  pro- 
cessus infundibuliformis  has  been  applied.  It  is  connected  with  the  cho- 
rion by  means  of  an  intermediate,  transparent,  gelatinous  substance,  of 
which  there  is  sometimes  a tolerably  thick  stratum.  It  gives  an  external 
coat  to  the  foetal  face  of  the  placenta,  and  to  the  funis  umbilicalis.  On 
dividing  the  navel  string,  we  find  the  chorion  between  the  amnion  and  the 
proper  substance  of  the  funis  itself.  The  placenta  and  funis,  then,  may 
be  said  to  be  behind  the  amnion  and  chorion,  in  the  same  way  as  the 
bowels  are  said  to  be  behind  the  peritoneum.  Its  use  is  exactly  analogous 
to  that  of  the  chorion,  so  far  as  affording  a covering  to  the  ovum  is  con- 
cerned ; but  it  performs  an  additional  distinct  function  in  the  secretion  of 
the  liquor  amnii. 

It  is  worthy  of  remark,  that  these  conjoint  membranes  do  not  always 
possess  the  same  degree  of  toughness ; for  we  sometimes  observe  them  in 
labour  so  exceedingly  tender,  that  they  break  on  the  very  first  accession  of 
pain;  while  at  others,  their  firmness  is  so  considerable  that  they  remain  entire 
much  longer  than  they  ought,  and  thus  proportionably  retard  the  delivery. 
In  some  few  instances,  they  have  not  been  ruptured  at  all  before  the  child’s 


76 


LIQUOR  AMNII. 


birth ; but  the  ovum  has  been  expelled  whole,  even  when  it  has  arrived 
within  a few  weeks  of  its  maturity.  Nor  do  they  increase  in  density  and 
strength  in  a relative  proportion  as  the  process  of  gestation  advances : for 
even  at  the  earliest  age,  they  resist  the  application  of  moderate  pressure ; 
and  at  five  or  six  months,  they  are  often  found  as  strong  as  they  usually  are 
at  the  expiration  of  the  whole  period : of  the  two  membranes,  the  amnion 
is  by  far  the  strongest. 

In  the  first  few  wreeks  of  gestation,  the  chorion  and  amnion  are  not  in 
contact  except  at  one  point,  there  being  a quantity  of  transparent  watery 
fluid,  resembling  the  liquor  amnii,  placed  between  them.  This  is  gradu- 
ally absorbed  during  the  progress  of  pregnancy,  until  it  entirely  disap- 
pears. Sometimes,  though  rarely,  there  still  remains  some  fluid  between 
the  membranes  at  the  close  of  pregnancy,  and  this  is  what  in  labour  is 
called  the  false  waters.  In  Plate  XVI.  fig.  58,  is  delineated  an  ovum  of 
about  five  weeks’  age,  in  which  the  outer  sac  (a,)  the  chorion,  has  been 
opened  to  display  ( b ,)  the  amnion  enclosing  the  embryo,  and  (c,)  the  vesi- 
cula  umbilicalis.  In  this  specimen,  the  chorion  is  of  far  greater  extent 
than  the  amnion,  and  there  existed  a proportionate  quantity  of  water 
between  them.  These  two  membranes  are  also  beautifully  shown  in  Plate 
XVI.  fig.  57,  representing  an  ovum  of  five  months  age.  The  foetus  is 
enclosed  within  the  amnion,  which  is  unopened,  and  is  separated  both 
from  the  chorion  and  placenta,  but  still  adherent  to  the  placental  extremity 
of  the  funis  : (a)  a portion  of  deciduous  membrane,  ( b , b)  the  placenta,  {e) 
the  chorion,  ( d ) the  amnion  with  the  foetus  within  it. 

Liquor  Amnii. — The  chorion  and  amnion,  as  well  as  the  two  layers  of 
the  decidua,  being  opened,  we  penetrate  into  the  centre  of  the  ovum,  and 
the  liquor  amnii  escapes.  This  is  the  name  given  to  the  waters  surround- 
ing the  foetus,  in  which  it  floats.  The  liquor  amnii  varies  exceedingly  at 
the  end  of  gestation,  both  in  its  quantity  and  properties : — in  quantity, 
from  a few  ounces  to  a gallon  or  more ; in  properties,  from  being  perfectly 
pellucid  and  inodorous,  to  a thick,  somewhat  viscid,  dirty  fluid,  nearly  as 
dark  as  a strong  infusion  of  coffee,  and  occasionally  of  a putrid  odour.  The 
usual  appearance  of  the  liquor  amnii  is  that  of  rather  dingy  water,  of  a 
greenish  or  yellowish  cast.  It  contains  some  salts,  especially  the  muriate 
of  soda,  and  phosphate  of  lime,  and  a free  acid  known  as  amnic  acid,  by 
some  supposed  to  be  benzoic  acid.  Urea  has  also  been  discovered  in  it; 
and  sometimes  a very  small  quantity  of  albumen  is  held  in  solution,  as  is 
evidenced  by  its  becoming  turbid  on  the  application  of  heat. 

The  relative  proportions  between  the  quantity  of  the  fluid  and  the  size 
of  the  embryo  differs  much  at  different  stages  of  pregnancy,  being  consi- 
derably greater  in  the  earlier  periods,  and  less  at  the  advanced  stage. 
Thus,  when  the  embryo  is  scarcely  visible  to  the  naked  eye,  there  is  from 


Stnc^caj'j- 


LIQOIJR  AMN1I. 


77 


half  a drachm  to  a drachm  of  water  collected  within  the  membranes.  In 
Plate  XV.  fig.  51,  where  the  embryo  is  not  so  large  as  a small  kidney- 
bean,  there  would  be  an  ounce  or  more  of  liquor  amnii ; while  at  the  end 
of  gestation,  when  the  foetus  weighs  on  an  average  nearly  seven  pounds, 
the  amount  of  fluid  seldom  exceeds  a quart.  The  quantity,  therefore, 
though  positively  increasing  with  the  growth  of  the  ovum  throughout 
the  whole  of  gestation,  is  relatively  to  the  size  of  the  foetus  gradually  dimi- 
nishing. 

The  origin  of  this  water  has  given  rise  to  much  controversy : it  has 
been  regarded  as  an  excretion  from  the  foetal  body, — either  urine  or  per- 
spiration. This,  however,  cannot  he,  because,  as  just  observed,  a quantity 
of  fluid  is  present  before  the  embryo  is  visible ; and  the  relative  proportion 
to  the  size  of  the  foetus  at  the  different  ages  of  pregnancy  would  also  dis- 
countenance such  an  idea.  It  has  been  supposed  to  be  a specific  uterine 
secretion ; but  in  extra-uterine  conception  it  is  found  surrounding  the 
foetus,  and  not  within  the  uterine  cavity.  It  is  now  generally  regarded  as 
a secretion  or  exudation  from  the  inner  surface  of  the  amnion,  supplied  by 
innumerable  colourless  vessels,  which  ramify  on  that  membrane. 

Use. — Nor  has  its  intention  or  use  been  a less  fruitful  ground  of  dispute. 
At  one  time  it  was  supposed  to  have  been  formed  for  the  purpose  of 
nourishing  the  foetus ; but  this  notion  is  very  unphilosophical ; — because  we 
can  assign  other  most  valuable  uses  to  it ; — because  we  have  no  need  of 
its  agency  in  this  respect,  since  there  is  a regular  system  of  vessels  con- 
nected with  the  foetus,  through  which  the  means  of  increase  can  be 
supplied ; — because  it  is  sometimes  perfectly  unfitted  for  nutriment,  being 
turbid,  and  occasionally  putrid; — because  it  is  proved  by  analysis  to 
contain  no  nutritious  properties,  or  if  any,  a very  inconsiderable  propor- 
tion ; — and  because  of  the  large  relative  quantity  in  the  first  few  weeks  of 
gestation.  Besides,  monstrosities  have  been  brought  forth  without  either 
oesophagus  or  digestive  apparatus.  Such  a production  could  not  have 
obtained  nourishment  by  means  of  internal  organs.  These  facts  have  led 
others  to  believe  that  it  nourished  the  foetus  by  absorption  through  the 
skin.  This  supposition  is  equally  improbable,  for  many  of  the  reasons  just 
stated  ; and  to  them  may  be  added,  that  as  the  liqour  amnii  is  secreted  by 
the  amnion,  which  is  continuous  with,  and,  as  it  were,  an  extension  of, 
the  foetal  skin,  we  cannot  concede  to  it  the  office  of  affording  a nutritious 
matter  to  be  afterwards  absorbed  by  the  cuticular  vessels. 

Its  real  use  appears  to  be,  to  defend  the  young  embryo,  in  the  early 
weeks  of  pregnancy,  from  the  pressure  of  the  uterine  parietes,  which 
must  otherwise  have  annihilated  it ; and  this  is  the  reason  why  it  then 
exists  in  such  large  proportionate  quantity ; — to  protect  the  vessels  of  the 
funis  and  placenta  in  the  latter  months  from  a degree  of  compression 


78 


PLACENTA. 


which  would  have  impeded  the  regular  flow  of  blood  through  them ; — 
and  to  allow  free  motion  to  the  limbs  of  the  foetus,  so  as  to  prevent  them 
being  cramped  or  distorted.  It  has  also  been  supposed  (since  water  is  so 
bad  a conductor  of  heat)  to  keep  up  an  equable  warmth  in  the  foetal  body 
throughout  the  whole  of  gestation,  to  whatever  varying  circumstances  of 
temperature  the  woman’s  person  may  be  exposed.  Besides  these  advan- 
tages, we  find  it  performing  a most  important  service  in  labour,  when  it 
conduces  so  essentially  to  the  formation  of  the  soft  wedge-like  bag.  Its 
value  does  not  cease  even  on  the  rupture  of  the  membranes ; for  it  assists 
in  lubricating  the  vagina  and  external  parts,  and  by  this  means  prepares 
them  for  the  more  easy  passage  of  the  child. 

Placenta. — Of  the  foetal  appendages — all  of  them  highly  essential 
towards  the  well  being  of  the  ovum,  either  at  the  early  or  more  advanced 
period  of  intra-uterine  life — the  placenta  is  perhaps  the  most  important ; — 
the  medium  of  communication  between  the  mother  and  her  infant ; — the 
organ  through  whose  means  life  is  sustained,  nourishment  supplied,  and 
growth  perfected. 

The  term  placenta  was  derived  from  its  shape.*  It  consists  of  a flat, 
spongy,  irregularly  circular  mass,  composed  entirely  of  foetal  vessels, — 
the  ramifications  of  the  umbilical  arteries  and  vein,  which  are  connected 
together  by  loose  cellular  substance.  It  is  usually  from  seven  to  nine 
inches  in  diameter,  and  about  one  inch  in  thickness  at  the  thickest 
part,  where  the  umbilical  vessels  enter  its  substance,  gradually  be- 
coming thinner"  towards  its  edge.  It  generally  weighs  about  a pound 
or  a little  more ; but  in  this  respect  it  varies  considerably,  its  bulk  being 
principally  influenced  by  the  size  of  the  child ; sometimes,  however,  its 
increased  weight  is  dependent  on  an  excess  of  its  own  growth  alone, 
probably  the  effect  of  diseased  action.  It  has  been  supposed  to  possess 
absorbents.  Hunterf  suggested  the  probability  of  these  vessels  being 
present;  Schrseger,  Wrisberg,  and  Chaussier,  contend  for  them;  and 
Fohmann  imagined  he  had  found  them  in  rich  profusion.  Sir  E.  Home 
and  Mr.  Bauer  believed  they  had  detected  nerves  by  the  aid  of  a strong 
magnifying  power ; and  this  is  also  the  opinion  of  Chaussier.  I have 
never  been  able  to  see  either  nerves  or  absorbents  in  this  organ,  or  in  the 
funis ; and  most  physiologists  deny  their  existence.  If  it  possessed 
absorbents,  it  is  to  be  presumed  that  they  would  be  sufficiently  evident  to 
the  eye  in  every  instance ; and  a strong  argument  against  there  being 
nerves  is  the  fact,  that  no  pain  is  felt  by  the  child  when  the  funis  is 
divided. 

* Placenta  in  the  Latin  language  signifies  a cake;  from  7rxamovcy  the  same. 

f M.  S.  Lectures  ; vide  Granville  on  abortion,  p.  19. 


PLxwr. 


60- 


& 


LIBRARY 

Of  THE  . _ 

CNIVERSI'iY  Of  1LUNOU 


Ml 


m 


PLACENTA. 


79 


It  has  two  faces : — the  one  foetal,  Plate  XVII.  fig.  60,  next  the  embryo ; 
the  other  maternal,  fig.  61,  in  apposition  to  the  uterus.  It  is  covered  on 
the  foetal  face  by  the  reflexed  decidua,  by  the  chorion  and  the  amnion  ; and 
on  the  maternal  by  the  decidua  vera.  The  foetal  surface  has,  therefore,  a 
smooth,  glistening  appearance,  which  it  obtains  from  the  two  ovular 
membranes ; these  are  raised  into  numerous  dark  coloured  ridges,  ra- 
diating in  a serpentine  manner  from  near  the  centre,  and  becoming  less 
evident  as  they  approach  the  edge;  produced  by  the  divisions  of  the 
umbilical  vessels,  before  they  dip  into,  and  bury  themselves  in,  the  sub- 
stance of  the  mass.  As  these  tortuous  eminences  are  vessels,  and  the 
largest  of  them  veins,  the  deepness  of  their  colour  depends  on  the  con- 
tained blood  shining  through  their  coats,  and  the  transparent  membranes 
covering  them.  The  maternal  surface  presents  a very  different  appear- 
ance. Invested  with  the  opaque,  flocculent,  fibrous  decidua,  it  puts  on  a 
fleshy  look,  and  is  divided  by  sulci  into  a number  of  irregularly  shaped 
lobes.  Each  of  these  lobes  is  formed  by  the  ramifications  of  one  branch 
of  the  umbilical  arteries  and  vein  on  their  first  splitting ; and  the  vessels 
of  one  lobe,  subdividing  in  an  arborescent  form,  anastomose  but  sparingly 
with  each  other,  and  not  at  all  with  those  of  its  neighbour.  The  decidu- 
ous membrane  is  carried  continuously  over  from  one  lobe  to  the  others, 
like  the  arachnoid  over  the  convolutions  of  the  brain,  and  does  not  pene- 
trate between  them  into  the  placental  structure.  By  some  anatomists 
nevertheless,  it  is  supposed  to  dip  deep  among  the  placental  vessels,  even 
to  the  foetal  face  of  the  organ. 

Use. — It  is  now  established  as  an  incontrovertible  fact,  that  the  salubri- 
ous change  which  the  foetal  blood  undergoes,  is  accomplished  in  the 
placental  mass ; but  the  immediate  mode  has  given  rise  to  much  difference 
of  opinion.  It  has  been  explained  in  four  ways.  Some  physiologists 
contend  that  there  is  a direct  communication  between  the  mother  and 
the  foetus  by  means  of  continuous  vessels.  Others,  that  the  mother’s 
blood  passes  by  absorption  into  the  foetal  system.  Others,  again,  that  the 
mother’s  blood  is  poured  into  certain  sinuosities  or  cells , existing  on  the 
maternal  surface  of  the  placenta,  which  are  destined  by  nature  to  receive 
it;  and  that  while  extra vasated  in. these  cells,  the  foetal  vessels  deprive  it 
of  whatever  is  necessary  for  the  preservation  of  the  embryo.  This  was 
the  theory  established  by  Hunter,  which  became  so  widely  disseminated 
and  followed.  This  physiologist,  therefoie,  considered  the  placenta 
divisible  into  two  distinct  portions, — a foetal  and  .maternal ; and  he  de- 
scribed also  two  separate  circulations  going  on  in  it  simultaneously,— -the 
one  of  the  mother,  the  other  of  the  child : — while  another  party  entirely 
denies  the  existence  of  the  placenta  cells ; and  supposes  that  the  same 
benefits  result  to  the  foetus — its  vessels  ramifying  in  close  approximation 


80 


PLACEN  T A. 


to  those  of  the  mother — although  the  mother’s  blood  never  enters  the 
placenta  at  all,  nor  ever  indeed  leaves  her  system. 

I am  myself  an  advocate  for  the  last  view.  Since  the  question,  how- 
ever, is  yet  in  dispute,  and  since  its  discussion  would  occupy  much  space, 
it  would  be  out  of  place  to  enter  upon  the  different  arguments  in  a work 
principally  directed  to  practical  objects.  But  rendering  the  blood  fitted 
for  the  continuance  of  life  is  not  the  sole  office  of  the  placenta ; it  is  the 
means  also  of  conveying  nourishment  to  the  foetus ; so  that  this  viscus 
performs  at  the  same  time  the  functions  of  two  of  the  most  important 
organs  of  breathing  life, — the  lungs  and  stomach. 

Attachment. — The  placenta  may  be  attached  to  any  part  of  the  internal 
surface  of  the  uterus,  and  it  necessarily  occupies  a space  equal  to  its  own 
diameter.  It  is  perhaps  most  usually  apposed  against  the  posterior  surface 
of  the  body;  but  occasionally  it  is  found  at  the  very  fundus,  more  rarely 
towards  the  neck,  and  more  seldom  still  over  the  mouth  itself ; in  which 
latter  case  its  position  must  necessarily  give  rise  to  much  loss  of  blood 
when  the  orifice  opens  in  labour. 

Its  attachment  is  by  simple  apposition , one  layer  of  the  decidua  being 
interposed  between  the  two  surfaces.  There  is  no  adhesion  in  the  natural 
condition  of  the  parts ; and  whenever  agglutination  does  take  place,  it  is 
the  consequence  of  diseased  action. 

Disease. — The  placenta  is  liable  to  organic  change  of  structure.  Thus 
it  is  sometimes  found  so  soft,  as  scarcely  to  bear  the  gentlest  handling 
without  being  broken.  At  other  times  it  is  much  firmer  than  common, 
although  no  other  morbid  alteration  can  be  observed  in  it.  At  others, 
granules  or  spiculse  of  bone  are  strewn  over  more  or  less  of  the  maternal 
face,  or  pervade  more  or  less  the  whole  substance ; so  that  when  the 
finger  is  run  over  it,  it  feels  as  though  it  had  been  dusted  with  coarse  sand. 
In  other  instances,  again,  solid  tumours,  bearing  much  the  appearance 
of  scirrhous  glands,  are  found  embedded  in  the  mass ; and  occasionally, 
but  very  rarely,  it  is  hydatidinous. 

Twin  placentae. — In  plural  gestation  a separate  placenta,  a separate 
funis,  a distinct  set  of  foetal  membranes,  and  a distinct  quantity  of  liquor 
amnii,  are  formed  for  each  child.  The  placentae  are  commonly  joined 
together  at  their  edge,  and  when  regarded  on  the  maternal  face,  they 
have  the  appearance  of  a single  organ.  But  the  vessels  of  the  one  do 
not  anastomose  with  those  of  the  other; — the  circulations  are  perfectly 
independent ; so  that  the  blood  of  one  child  does  not  pass  into  the  system 
of  its  brother.  One  of  the  twins  may,  therefore,  still  live  after  the  other 
has  died ; — one  may  be  healthy  while  the  other  is  the  subject  of  disease, 
Plate  XVIII.  fig.  G3. 

It  occasionally  happens,  indeed,  that  a communication  exists  between 


UMBILICAL  CORD. 


81 


the  vascular  systems  of  the  two  children,  though  they  are  both  enveloped 
in  separate  membranes ; and  it  has  been  also,  though  very  seldom,  re- 
marked, that  both  were  wrapped  up  in  the  same  bag  of  membranes;  and 
that  the  funis  having  arisen  by  one  branch  from  the  single  placenta,  has 
split  into  two  divisions  to  supply  each  foetus. 

Battledore  placenta. — The  navel  string  usually  enters  the  placenta  near 
the  middle;  but  it  sometimes  passes  into  U at  the  edge;  and  not  unfre- 
quently  the  vessels  divide  into  a number  of  branches  before  they  arrive  at 
the  substance  of  the  mass.  To  this  formation  the  name  of  the  battledore 
placenta  is  given ; Plate  XVIII.  fig.  G4 ; and  it  is  of  importance  in  prac- 
tice, that  this  deviation  from  the  natural  condition  should  be  borne  in 
mind;  because  if  attempts  were  made  to  remove  a placenta  of  this 
description  by  traction  at  the  funis,  as  soon  as  the  insertion  of  the  vessels 
into  its  substance  could  be  felt  by  the  finger, — while  the  great  part  of  its 
bulk  was  still  in  utero, — much  danger  might  be  induced ; as  will  be  shown 
in  an  after  part  of  this  publication. 

The  Funis  Umbilicalis,  umbilical  cord,  or  navel  string,  is  a rope-like 
cord  running  from  the  navel  of  the  child  into  the  body  of  the  placenta— a 
framework  for  the  transmission  of  blood-vessels.  It  varies  much  in  length; 
in  some  instances  not  exceeding  six  or  seven  inches;  in  others  being  more 
than  five  feet.  Its  average  length  may  be  regarded  as  from  eighteen  to 
twenty-four  inches.  It  varies  also  in  thickness,  and  this  depends  on  the 
larger  or  smaller  quantity  of  a viscid  semi-transparent  gelatinous  matter, — 
the  gelatine  of  Wharton — contained  in  cells,  which  constitutes  the  principal 
part  of  the  thickness  of  the  cord.  These  cells  do  not  communicate  with 
each  other  freely.  Both  the  cells  and  the  contained  gelatine  are  evidently 
for  the  purpose  of  protecting  the  blood-vessels  from  pressure.  Plate  XVII. 
fig.  62,  shows  a portion  of  the  funis  cut  longitudinally;  the  dark  spaces 
are  the  cavities  of  the  arteries  and  veins  unoccupied  ; the  lighter  parts 
show  the  reticular  cells  filled  with  mercury.  The  preparation  from  which 
this  drawing  was  taken,  proves  how  slight  the  connexion  between  the 
cells  must  be ; else,  as  the  funis  is  suspended  from  one  extremity  in  the 
spirit  which  preserves  it,  the  mercury  would  run  out  by  its  own  weight. 

The  funis  gives  a passage  to  three  blood-vessels — two  umbilical  arte- 
ries and  one  umbilical  vein.  The  arteries  are  longer  than  the  vein, 
being  considerably  more  tortuous;  and  they  generally  continue  their 
course  in  a spiral  direction,  running  round  the  vein ; in  the  majority  P'* 
of  cases  being  twisted  from  the  left  to  the  right.  Plates  XVII.  figs. 

60  and  61,  and  XVIII.  figs.  63  and  64.  They  sometimes  form  simple 
turns  upon  themselves,  as  seen  in  Plate  XVII.  fig.  65,  (a  a;)  at  others 
they  are  twisted  into  fantastic  convolutions,  giving  the  external  surface  of 
11 


82 


UMBILICAL  CORD. 


the  cord  a knotty  appearance,  not  unlike  varices  in  the  legs.  Plate 
XVIII.  fig.  64,  (a.)  They  will  then  run  for  some  length  straighter  and 
nearly  parallel  to  the  vein.  Sometimes  the  funis  itself  is  found  in  labour 
to  be  twisted  into  a loose  knot ; but  this  appears  to  me  to  be  produced 
rather  by  the  movements  of  the  foetus  in  utero,  than  to  exist  as  an  original 
conformation.  The  vein  is  much  greater  in  its  calibre  than  the  two 
arteries  together;  but  as  the  latter  vessels  are  perhaps  twice  the  length  of 
the  vein  or  more,  the  quantity  of  blood  actually  contained  in  the  two 
arteries  at  one  time  may  be  nearly  the  same  as  in  the  vein. 

The  vein  possesses  no  valves ; and  the  arteries  do  not  communicate 
with  each  other  until  they  reach  the  placenta ; when  one  generally  sends 
off  a large  transverse  branch  to  the  other.  The  arteries  carry  adulte- 
rated blood  from  the  body  of  the  foetus  to  the  placenta,  and  have  a very 
strong  pulsation ; the  vein  carries  back  again  to  the  foetus,  pure  blood 
imbued  with  the  principles  of  both  vitality  and  nourishment.  In  some 
respects,  then,  these  canals  may  be  likened  to  the  pulmonary  vessels ; but 
the  umbilical  vein,  by  transmitting  the  means  of  growth,  as  well  as  of  the 
continuance  of  vitality,  performs  an  office  superior  in  value  to  the  pulmo- 
nary veins,  which  give  passage  to  fluid  fraught  with  the  principles  of  life 
alone.  Whether  much  difference  of  colour  exists  in  the  blood  transmitted 
by  the  vein  and  that  circulating  in  the  arteries,  is  a point  not  very  easy  to 
determine.  Granville  and  Mayo  assert  that  the  colour  of  the  blood  in  the 
umbilical  vein  is  somewhat  lighter  than  that  in  the  arteries.  Meckel  and 
Blundell,  again,  think  there  is  no  manifest  difference,  and  that  both  con- 
tain an  equal  quantity  of  carbon.  But  while  we  know  that  breathing  life 
cannot  be  sustained  without  some  alteration  being  effected  on  the  blood 
through  the  influence  of  the  atmosphere,  and  that  even  aquatic  animals  are 
furnished  with  organs  for  the  express  purpose  of  purifying  their  blood,  it 
is  not  too  much  to  assume  that  a similar  change  is  required  for  preserving 
the  vitality  of  the  foetus;  and  that  this  function  is  carried  on  by  the 
placenta. 

Although  there  is  much  variation  in  the  straightness,  or  tortuosity , we 
very  rarely  meet  with  any  variety  in  the  number  of  the  umbilical  vessels. 
In  two  specimens  preserved  in  the  London  Hospital  Museum,  there  is 
only  one  umbilical  artery ; and  Dr.  Hunter  mentions  that  he  had  seen 
many  instances  of  such  deviation,  but  none  in  which  there  were  two  veins. 
Velpeau,  however,  states  that  two  veins  have  been  met  with,  and  refers 
to  Guillemot  for  authority.  As  far  as  regards  the  arteries,  I do  not  know 
of  any  case  on  record,  in  which  either  of  the  internal  iliacs  sent  off  two 
umbilical  branches,  so  as  to  form  three  arteries  in  the  cord.  Both  the 
blood-vessels  and  cells  are  covered  by  the  amnion  and  chorion ;— the 
amnion  being  here,  as  on  the  foetal  face  of  the  placenta,  external. 


TLXvnr 


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URACHUS. 


83 


The  rapidity  of  the  circulation  through  the  cord  has  been  a subject  of 
frequent  discussion  ; and  the  probability  is,  that  it  differs  much  in  different 
individuals,  and  in  the  same  individual  foetus  at  different  times.  The 
number  of  pulsations  generally  ranges  at  one  hundred  and  twenty  or  one 
hundred  and  thirty  in  the  minute ; but  it  seems  that  the  foetal  circulation 
is  greatly  influenced  not  only  by  causes  existing  within  its  own  system, 
but  by  accidental  circumstances  affecting  the  mother,  and  external  agen- 
cies to  which  her  person  may  be  exposed.  Both  the  mental  passions  and 
the  loss  of  blood  from  the  mother’s  body,  with  many  other  causes,  have  a 
decided  effect  on  the  foetal  pulse. 

The  funis  is  often  found  coiled  round  the  neck  or  limbs  of  the  foetus ; 
and  this  may  embarrass  us  in  practice. 

When  the  embryo  is  first  visible,  in  the  earlier  weeks  of  utero-gestation, 
we  see  nothing  like  a funis  umbilicalis,  but  the  newly-formed  being  is 
attached  by  its  abdomen  directly  to  the  amnion.  It  appears  first  about 
the  end  of  the  fifth  week:  for  some  time  it  contains  a much  larger  pro- 
portion of  gelatine  than  during  the  latter  months ; and  the  vessels,  which 
before  were  perfectly  straight,  Plate  XV.  fig.  51  ( e ,)  assume  a twisted 
character  about  the  end  of  the  tenth  week. 

Disease. — The  umbilical  cord  is  liable  to  disease ; the  most  frequent 
derangement  in  its  structure,  perhaps,  is  the  secretion  of  too  large  a quan- 
tity of  gelatine  in  its  cells.  This,  if  considerable,  may  obstruct  the  flow 
of  blood  through  the  vascular  ducts,  and  occasion  the  death  of  the  foetus. 
Thus,  a diseased  condition  of  the  funis  may  indirectly  lead  to  abortion. 
Plate  XV.  fig.  55,  shows  an  ovum,  in  which  the  funis  is  much  greater  in 
circumference  than  it  should  be,  owing  to  there  having  been  too  much 
gelatine  formed.  It  destroyed  the  life  of  the  embryo  ; but  the  ovum  was 
retained  in  utero  for  some  time  after  the  cessation  of  its  vitality,  as  is 
proved  by  the  thickness  and  solidity  which  the  involucra  have  acquired. 

Urachus. — In  the  quadruped,  besides  the  blood-vessels,  there  is  another 
pervious  duct  running  along  the  funis  called  the  Urachus.  This  rises  at 
the  fundus  of  the  bladder,  passes  out  of  the  foetal  body  at  the  navel,  and 
accompanying  the  blood-vessels  as  far  as  the  ovular  membranes,  continues 
its  course  till  it  terminates  in  a bag  between  the  amnion  and  chorion, 
called  the  allantois  ; thus  the  cavity  of  the  bladder  communicates  with 
the  allantois  by  means  of  the  urachus.  In  the  human  subject  there  is  no 
duct;  but  an  impervious  cord  runs  up  from  the  fundus  of  the  bladder,  and 
is  lost  at  the  umbilicus.  This  is  also  called  the  urachus ; but  it  is  not 
generally  continued  along  the  funis,  and  there  is  no  cavity  between  the 
ovular  membranes  resembling  the  allantois. 


84 


UMBILICAL  VESICLE. 


The  Vesicula  Umbilicalis,  or  Vesicula  Alba,  constitutes  also  a part  of 
the  ovum  in  its  early  stage.  It  is  a small  sac,  not  larger  at  its  greatest 
magnitude  than  a pea  or  swan-shot,  situated  between  the  amnion  and 
chorion,  possessing  a pellucid  coat,  and  enclosing  a small  quantity  of  vis- 
cid transparent  fluid,  whitish,  or  more  generally  rather  of  an  amber  colour. 
The  largest  on  record  is  mentioned  by  Lobstein : this  measured  six  lines 
in  diameter.  Its  appearance  is  confined  to  a particular  stage  of  preg- 
nancy, being  first  noticed  during  the  early  part  of  the  second  month, 
according  to  most  observers;  but  Velpeau  speaks  of  it  being  the  size  of  a 
pea  on  the  fifteenth  or  twentieth  day  from  impregnation,  and  says  that  it 
has  acquired  its  greatest  magnitude  during  the  third  or  fourth  week.  It 
is  generally  believed,  however,  to  enlarge  till  about  the  middle  of  the  third 
month,  when  its  contained  fluid  becomes  thicker  and  opake ; the  vesicle 
itself  then  begins  to  dwindle  in  size,  and  speedily  disappears  altogether. 
Hunter,  Meckel  and  others,  have  observed  it.  at  the  end  of  gestation. 
When  however,  it  persists  longer  than  usual,  it  does  not  continue  to 
increase,  but  at  the  close  of  pregnancy  is  as  small  as  it  was  at  the  end  of 
three  months. 

From  one  extremity  of  the  vesicle  a duct  is  sent  out  to  join  the  funis 
umbilicalis,  becoming  thinner  as  it  recedes  from  the  bag,  until  to  the  naked 
eye  it  is  lost  upon  the  cord  itself.  It  may  be  traced,  nevertheless,  by  mag- 
nifying glasses  running  along  the  funis,  entering  the  body  of  the  embryo, 
and  eventually  communicating  with  the  cavity  of  the  caecum  or  with  the 
ilium,  just  where  it  joins  the  last-named  intestine.  The  distance  between 
the  vesicle  and  that  end  of  the  funis  farthest  from  the  body  of  the  embryo 
varies,  being  sometimes  not  more  than  half  an  inch,  at  others  twice  or 
three  times  as  much. 

It  is  supplied  with  blood  by  a distinct  artery  and  vein,  called  the 
omphalo-mesenteric  vessels ; the  artery  proceeds  from  the  inferior  mesen- 
teric, passes  between  the  convolutions  of  the  intestines  to  the  umbilicus, 
and  thence  along  the  funis ; the  vein  arises  from  the  walls  of  the  vesicle, 
traverses  the  funis  in  company  with  the  artery,  and  finally  terminates  in 
the  superior  mesenteric  vein,  before  that  vessel  enters  the  porta.  The 
omphalo-mesenteric  vessels  shrivel  as  the  vesicle  itself  disappears.  They 
have  been  observed,  indeed,  both  by  Chaussier  and  Beclard,  in  the  funis  of 
a full-grown  foetus,  dwindled  into  white  impervious  cords. 

Its  use  is  still  involved  in  some  degree  of  mystery.  The  best  explana- 
tion is  offered  by  Velpeau ; he  supposes  the  fluid  it  contains  to  be  nutritious, 
and  intended  to  contribute  to  the  development  of  the  embryo,  until  the 
cord  and  umbilical  vessels  are  elaborated.  It  is,  according  to  him, 
analogous  to  the  vitelline  sac  of  the  chick  ; which  it  resembles  in  shape, 
position,  and  connexion  with  the  intestines,  structure,  and  the  character  of 


FCETUS. 


85 


the  contained  fluid.  We  must  acknowledge,  however,  that  there  is  a 
material  difference  between  the  two ; because,  in  the  chick,  the  ductus 
vitello-intestinalis  is  constantly  becoming  shorter,  until  the  whole  bag  is 
received  into  the  abdominal  cavity ; while  in  the  human  ovum  the  vesi- 
cula  umbilicalis  is  in  close  approximation  to  the  abdomen  of  the  embryo 
until  the  formation  of  the  funis;  after  which,  its  duct  elongates  as  gestation 
advances ; and  it  consequently  recedes  from,  instead  of  approaching  nearer 
to,  the  foetal  body. 

In  Plate  XYI.  are  represented  two  specimens  of  the  umbilical  vesicle. 
Fig.  58  shows  the  vesicle  (c)  floating  loosely,  detached  both  from  the 
amnion  ( b ) and  chorion  (a;)  it  is  suspended  by  the  duct  containing  the 
omphalo-mesenteric  vessels  : the  embryo  is  seen  enclosed  in  the  amnion. 
This  ovum  I should  consider  to  be  between  five  and  six  weeks  old,  but  I am 
not  acquainted  with  its  history.  Fig.  59  gives  the  vesicle  (a)  in  its  natural 
position  between  the  ovular  membranes,  its  fluid  having  already  become 
opake.  This  ovum  is  at  least  seven  weeks  old. 


THE  FOETUS. 


The  different  constituents  of  the  ovum,  which  have  been  already  de- 
scribed, are  formed  solely  for  the  protection,  preservation,  and  growth  of 
the  foetus  : — to  its  necessities  all  the  other  parts  are  contributory  and  sub- 
servient. At  the  end  of  gestation  the  foetus  ordinarily  measures  about 
twenty  inches  from  the  crown  of  the  head  to  the  heel,  and  weighs  nearly 
seven  pounds : but  there  is  an  amazing  difference  in  both  these  respects, 
particularly  the  latter ; and  the  size  is  influenced  by  circumstances  not 
very  easily  explained.  Generally  speaking,  males  weigh  more  than 
females  by  one  or  two  ounces,  and  are  longer  by  a third  or  half  an  inch. 
Some  children  at  full  time  have  been  known  to  w7eigh  even  less  than  five 
pounds;  while  many  cases  are  on  record  where  the  wreight  exceeded 
double  the  average.  Thus  Baudelocque  mentions  that  he  has  seen  one 
child  at  birth  which  weighed  twelve  pounds,  and  another  thirteen.*  The 
late  Dr.  Merriman  delivered  a woman  of  a foetus  that  weighed  more  than 
fourteen  pounds.f  Sir  Richard  Croft  saw  one  born  alive  of  fifteen  pounds.J 
Spence  gives  a case  in  which  the  child  and  placenta  together  weighed 
sixteen  pounds  Dutch  weight,  after  the  brain  had  been  evacuated.§  My 

* L’Art.  des  Accouchemens,  parag.  432. 

t Communicated  to  me  by  Dr.  Samuel  Merriman. 

t Communicated  by  the  same  gentleman.  See  also  Hutchinson  on  Infanticide,  p.  15. 

§ System  of  Midwifery,  case  xxv. 


8G 


F CE  T U S. 


father  once  delivered  a woman  of  a foetus  that  weighed  sixteen  pounds 
and  a half  avoirdupois.*  Dr.  Moore,  of  New  York,  states  that  in  1821 
a child  was  born  in  that  city  that  also  weighed  sixteen  pounds  and  a 
half.-)-  And  Mr.  J.  D.  Owens  assisted  at  the  birth  of  a child,  which 
weighed  seventeen  pounds  twelve  ounces ; and  whose  length  was  twenty- 
four  inches.J  This,  as  far  as  I know,  is  the  heaviest  well-authenti- 
cated foetus  on  record.  Of  the  three  largest  children  I w7as  ever  my- 
self at  the  birth  of,  one  weighed  fourteen  pounds;  this  was  a breech 
presentation,  and  the  child  was  born  dead : another  was  twelve  pounds 
and  one  ounce ; this  I extracted  by  the  forceps ; it  was  also  dead : the  last 
weighed  twelve  pounds  and  three  quarters ; this  was  expelled  naturally ; 
it  gasped  two  or  three  times,  but  could  not  be  restored. 

The  usual  'position  in  which  the  foetus  lies  in  utero  is  the  most  easy,  as 
vrell  as  compact,  that  could  possibly  be  devised  for  a body  of  such  bulk 
and  irregularity.  Its  general  figure  is  that  of  an  oval,  the  long  diameter 
being  placed  nearly  perpendicularly  as  regards  the  trunk  of  the  mother. 
The  head  is  situated  towards  the  os  uteri,  the  vertex  being  the  most  depen- 
dent part ; the  chin  is  pressed  upon  the  chest ; the  neck  and  back  are  bent 
into  a curve ; the  nates  lie  at  the  fundus  uteri ; the  thighs  are  flexed  up 
towards  the  belly,  and  the  legs  somewhat  turned  back  upon  the  thighs ; 
the  arms  are  crossed  upon  the  chest;  or  one  hand  is  placed  by  the  side  of 
the  head,  and  the  other  on  the  chest  or  by  the  breech ; sometimes  both  lie 
by  the  side  of  the  head ; or  they  may  be  otherwise  variously  disposed. 
Thus  one  end  of  the  oval  is  formed  by  the  vertex,  and  the  other  by  the 
breech ; and  its  adaptation  to  the  cavity,  in  which  it  is  placed,  is  most 
perfect. 

In  Plate  XIX.,  fig.  66,  the  foetus  at  maturity  is  seen  folded  as  it  com- 
monly lies  in  utero. 

The  quantity  of  matter  that  is  contained  within  the  gravid  uterus  at  the 
end  of  gestation,  provided  we  allow  seven  pounds  for  the  foetus,  one  pound 
and  two  or  three  ounces  for  the  placenta  and  membranes,  and  above  a 
pound  for  the  liquor  amnii, — will  be  between  nine  and  ten  pounds  in  all. 
But  this  will  differ  not  only  according  to  the  size  of  the  foetus  and  placenta, 
but  also  according  as  the  water  has  been  more  or  less  largely  secreted. 

* Practical  Observations  in  Midwifery,  case  liii. 
t New  York  Med.  and  Phys.  Journal,  vol.  ii.  p.  20. 
t Lancet,  vol.  i.  1838-39,  p.  477. 


m 

PI.  XIX. 


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f 


DEVELOPMENT  OF  THE  UTERUS. 


87 


DEVELOPMENT  OF  THE  UTERUS. 

The  uterus  is  constantly  enlarging  during  the  whole  term  of  gestation, 
and  its  increase  corresponds  with  that  of  the  ovum ; so  that  its  growth 
towards  the  close  of  pregnancy  is  comparatively  greater  from  week  to 
week  than  at  any  other  period.  The  fundus  and  body  are  first  evolved ; 
and  the  neck  does  not  begin  to  expand  until  full  five  months  have  passed. 
Before  this  time  the  principal  part  of  the  organ  is  globular  in  shape,  and 
the  elongated  cervix  projects  from  it  below,  as  is  seen  in  Plate  XX.  fig.  67, 
which  is  copied  from  hunter’s  work,  and  represents  the  back  face  of  the 
gravid  uterus,  and  vagina  at  the  commencement  of  the  fifth  month.  But 
in  the  sixth  month  the  fibres  of  the  uterine  neck  begin  to  develope  them- 
selves ; they  become,  as  it  were,  unfolded — the  process  commencing  from 
above,  and  by  degrees  progressing  downwards, — and  at  the  end  of  gesta- 
tion the  cervix  is  so  completely  opened  out,  that  it  forms  part  of  the  gene- 
ral cavity.  Figs.  68,  69  and  70.  Plate-  XX.  show  the  gradual  change 
taking  place  in  the  neck  of  the  womb.  Fig.  68,  represents  it  at  the  end  of 
the  third  month ; fig.  69,  at  the  end  of  six  months ; and  fig.  70,  just  before 
labour  begins.*  The  enlarged  glandulse  Nabothi  are  also  well  delineated  i 
and  the  fissured  character  that  the  os  uteri  sometimes  assumes  towards 
the  termination  of  pregnancy  is  seen  in  figure  70. 

The  parietes  do  not  become  thinner  as  the  uterus  grows,  but  in  many 
instances  absolutely  thicker.  They  are  not  distended  by  their  contents  as 
a bladder  might  be  blown  up ; and  the  cavity  is  never  so  completely  filled, 
but  that  it  would  hold  somewhat  more  than  it  contains.  The  enlarge- 
ment is  dependent  on  a process  of  healthy  evolution ; and  if  any  pres- 
sure or  distention  from  within  occurs,  as  is  the  case  when  a preterna- 
turally  large  quantity  of  liquor  amnii  is  formed,  much  inconvenience  and 
pain  result. 

Great  as  is  the  increase  of  the  womb  in  its  general  bulk,  the  blood-ves- 
sels undergo  an  enlargement  even  far  more  considerable  in  proportion ; 
and  this  is  explained  by  the  fact  that  they  have  not  only  to  nourish  the 
parietes,  but  also  to  supply  the  wants  of  the  growing  foetus.  It  is  this 
circumstance  which  renders  the  texture  of  the  gravid  womb  so  loose  and 
ductile ; and  the  amazing  diameter  they  have  acquired  before  labour  com- 
mences, most  readily  accounts  for  the  violent  hemorrhages  that  not  unfre- 
quently  attend  on  parturition. 

This  alteration  in  the  size  of  the  blood-vessels  mainly  contributes  to  the 
increase  of  the  uterine  parietes ; there  is  nevertheless  an  additional  quantity 
of  both  cellular  and  fibrous  matter  secreted,  as  the  evolution  proceeds. 

* These  three  figures  are  about  the  natural  size. 


88 


DEVELOPMENT  OF  THE  UTERUS. 


The  nerves  and  absorbents  also  partake  of  the  general  enlargement; 
though  not  to  so  great  a degree  as  the  blood-vessels. 

For  the  first  weeks  of  gestation  the  uterus  descends  somewhat  lower 
towards  the  outlet  of  the  pelvis  than  the  position  it  previously  held  ; and 
this  subsidence  often  occasions  troublesome  and  annoying  symptoms,  such 
as  pressure  on  the  absorbents  and  veins,  producing  oedema  and  varices;  and 
on  the  nerves,  causing  cramp.  Nor  do  the  bladder  and  rectum  escape  ; 
and  a frequent  inclination  to  evacuate  the  intestine,  but  more  particularly 
constant  calls  to  pass  urine,  are  among  the  many  distresses  consequent  on 
early  pregnancy. 

About  the  end  of  the  fourth  month  it  begins  to  mount  from  the  pelvis 
into  the  abdomen ; and  its  fundus  may  then  be  felt  emerging  above  the 
symphysis  pubis.  The  time  of  its  residence  within  the  pelvis,  however, 
will  much  depend  on  the  size  of  that  organ.  The  smaller  the  capacity, 
the  sooner  will  it  rise ; and  if  the  dimensions  be  preternaturally  large,  it 
will  remain  a tenant  of  the  cavity  for  a proportionably  longer  period. 
In  its  ascent  it  passes  before  the  intestines,  carrying  the  omentum  up 
above  it ; and  when  it  has  nearly  acquired  its  extreme  bulk,  the  colon  lies 
along  its  fundus ; and  it  encroaches  in  some  degree  on  the  space  occupied 
by  the  stomach.  Plate  XXI.  fig.  71. 

It  is  not  to  be  supposed  that  these  changes  can  go  on  in  the  uterus 
without  the  viscera  in  connexion  with  it  being  also  materially  affected  in 
regard  to  their  relative  situations.  Thus  the  neck  of  the  bladder  is  some- 
what drawn  up  with  the  neck  of  the  ascending  uterus.  But  the  principal 
alteration  is  observed  in  the  peritoneum,  the  Fallopian  tubes,  the  broad 
ligaments,  and  the  ovaries.  The  peritoneal  covering  is  of  necessity  greatly 
extended  in  surface ; and  this  depends  partly  on  the  formation  of  new 
membrane,  a fresh  secretion, — partly  on  its  allowing  itself  to  be  stretched 
out  in  every  direction,  (for  it  is  highly  elastic,  as  is  shown  in  the  varia- 
tions of  contraction  and  distention  which  the  stomach,  intestines,  and 
bladder,  are  constantly  undergoing,  and  in  the  descent  of  that  portion  of 
the  membrane  which  constitutes  the  sac  in  hernia ;) — and  partly  on  the 
layers  of  the  broad  ligaments  splitting,  and  receiving  the  sides  of  the 
uterus  between  their  folds.  This  latter  cause  occasions  the  ovaries  to  be 
drawn  nearer  to  the  substance  of  the  organ  than  they  are  in  their  natu- 
ral condition ; while,  from  the  same  cause,  both  the  broad  and  round 
ligaments  run  almost  perpendicularly  downwards  to  the  pelvic  brim,  in- 
stead of  horizontally  as  in  the  unimpregnated  state.  The  Fallopian 
tubes  also,  from  the  disposition  of  the  ligaments,  lie  for  some  distance 
upon,  and  in  close  approximation  to,  the  body  of  the  uterus.  At  the  ter- 
mination of  pregnancy,  the  womb  measures  about  thirteen  inches  in 
length  and  eight  or  nine  in  breadth ; and  it  has  acquired  an  ovoid  figure, 
Plate  XXI.  fig.  71. 


j 


PI  XX 


&7- 


JTitf.  00. 


FI#.  70 


Si,ncla/£r!s‘ 


Sinclair's,  * 


ON  LABOUR. 


When  gestation  is  completed,  the  uterus,  which  during  the  period  of  its 
f growth  was  inert,  allowing  itself  to  be  evolved  and  acquiring  a surprising 
size,  begins  a new  action,  which  constitutes  the  function  of  labour,  or 
parturition.  These  simple  terms  designate  a very  complicated  process, 
embracing  the  dilatation  of  the  passages,  as  well  as  the  expulsion  of  the 
ovum. 

The  principal  agent  in  labour  is  the  uterus  itself ; but  it  is  much  assisted 
in  its  action  by  the  contraction  of  the  abdominal  muscles,  and  probably 
also  of  the  diaphragm. 

Under  labour  the  foetus  is  perfectly  passive : so  that  a dead  child  is 
expelled,  generally  speaking,  nearly  with  the  same  ease  as  a living  one. 
The  ancients,  indeed,  thought  that  the  infant,  by  its  own  struggles,  con- 
tributed a great  share  in  procuring  its  freedom ; and  iEtius — who  lived 
towards  the  end  of  the  fifth  century,  and  whose  works  principally  consist 
of  a compilation  from  those  of  previous  authors — especially  mentions  the 
death  of  the  foetus  as  one  cause  of  difficult  labour;  since  it  could  give  no 
assistance,  by  reason  of  its  being  still.*  We  may  presume  this  was  a 
prevailing  doctrine  before  the  time  of  this  writer,  and  it  continued  so  for 
many  centuries  after.f 

The  action  of  the  uterus  is  perfectly  involuntary,  and  consists  in  a con- 
traction of  the  fibres  imbedded  in  its  structure,  which  indeed  form  its 
peculiar  parenchyma.  These  fibres  obey  in  labour  the  laws  of  muscular 
action ; their  extremities  are  brought  nearer  together,  and  in  the  same 
proportion  as  their  length  is  diminished,  they  become  increased  in  thick- 
ness. Thus,  inasmuch  as  the  fibres  run  throughout  the  uterus,  traversing 
it  in  all  directions,  every  part  of  the  uterine  structure  is  lessened  in  extent, 
the  capacity  of  the  uterine  cavity  is  decreased,  and  the  internal  membrane 

* Discourse  16,  chap.  xxi.  of  Cornarius’  translation, 
t Vide  Mauriceau,  livre  ii.  chap.  10. 


12 


90 


labour,  {Symptoms.) 

is  brought  into  forcible  contact  with  the  contents.  By  this  contraction 
pressure  is  exerted,  propulsion  is  produced,  and  eventually  expulsion  is 
effected.  Even  after  the  child  is  born  the  same  kind  of  contraction  goes 
on  in  the  uterine  parietes,  for  the  purpose  of  expelling  the  placenta,  and  of 
gradually  closing  the  open  vessels.  It  is  by  this  contraction  that  hemor- 
rhage is  prevented,  and  the  safety  of  the  patient  in  that  respect  ensured. 

But  the  auxiliary  muscles  which  assist  the  uterus  in  its  contractions  are 
in  a great  degree  voluntary;  so  that  labour  may  be  said  to  consist  of  a 
mixed  action ; partly  of  a voluntary,  but  principally  of  an  involuntary 
character:  for  the  aid  which  the  woman  contributes  by  the  exertion  of 
her  own  will  is  not  to  be  compared  to  the  propelling  power  of  the  uterus, 
which  is  entirely  independent  of  her  control. 

The  general  features  of  labour  are  the  same  in  all  cases,  but  there  is 
an  infinite  diversity  in  the  details.  Sometimes  it  is  complicated  with 
irregularities  and  dangers ; it  is  always  attended  with  more  or  less  of 
suffering,  if  the  patient  be  conscious.  The  duration  of  the  process  and 
the  pain  suffered,  vary  much  in  different  women,  and  in  the  same  woman 
in  different  pregnancies.  The  pain  endured  is  sometimes  regulated  by 
the  strength  of  the  uterine  contractions;  sometimes  by  the  resistance 
offered  to  the  child  in  its  passage ; but  frequently  it  depends  on  the  degree 
of  irritability  or  sensibility  possessed  by  the  uterus  itself.  There  is  no 
doubt  that  this  organ  in  some  women  is  much  more  sensitive  than  in 
others;  and  we  may  fairly  presume  that  in  the  same  woman  it  is  much 
more  sensitive  at  one  labour  than  at  any  previous  or  subsequent. 

The  Symptoms  of  Labour  may  be  classed  under  two  heads : — those  which 
are  indicative  of  the  approaching  crisis, — and  those  which  intimate  that 
the  process  has  actually  commenced. 

The  symptoms  indicative  of  approaching  labour  are,  first,  a subsidence 
of  the  uterine  tumour ; secondly,  an  increased  moisture  and  laxity  of  the 
vagina  and  external  organs ; — thirdly,  a peculiar  degree  of  mental  anxiety. 

1st.  When  about  eight  months  and  a half  of  utero-gestation  have  passed, 
the  uterus  has  acquired,  not  perhaps  its  largest  size,  but  its  greatest  height 
in  the  person ; its  fundus  has  then  pretty  nearly  reached  to  the  ensiform 
cartilage.  But  at  the  end  of  nine  months  it  has  generally  sunk  back  to 
the  situation  which  it  occupied  at  the  end  of  eight ; so  that  its  fundus  may 
be  felt  half  way  between  the  ensiform  cartilage  and  the  umbilicus.  This 
diminution  in  volume  occurs  indeed  sometimes  suddenly, — during  the 
course  of  one  night  for  instance, — and  the  woman  on  rising  from  her  bed 
is  surprised  to  find  herself  so  much  less  than  she  was  the  day  preceding. 
But  more  frequently  it  is  gradual,  almost  imperceptible  from  day  to  day, 
but  sufficiently  obvious  after  the  lapse  of  several.  It  is  partly  produced 
by  painless  contraction  going  on  in  the  uterine  fibres  themselves,  and 


91 


labour,  {Symptoms.) 

partly  by  the  subsidence  of  the  organ  within  the  pelvic  cavity.  It  is  to 
be  regarded  as  a good  symptom ; for  it  shows  us  that  labour  is  disposed 
to  commence  in  a natural  manner;  and  also — especially  is  this  knowledge 
valuable  in  a first  pregnancy — that  the  woman  has  a tolerably  roomy 
pelvis;  for  if  any  portion  of  the  head  will  enter  the  brim,  while  covered 
by  the  cervix  uteri,  it  is  reasonable  to  expect  that  it  will  readily  descend 
into  the  cavity  when  the  os  uteri  is  dilated.  It  is  a remark  constantly 
made  by  women  when  within  a day  or  two  of  their  confinement,  that 
they  are  both  smaller  in  size  and  feel  lighter  and  more  active  in  their  per- 
sons than  they  had  done  for  some  weeks  before.  This  is,  however,  by  no 
means  a universal  occurrence,  and  it  is  not  to  be  looked  for  in  cases 
where  there  exists  a contraction  of  the  pelvic  entrance. 

2nd.  The  second  indication  of  approaching  labour  is  increased  moisture, 
relaxation,  and  distensibility  of  the  vagina  and  external  parts,  together 
with  some  slight  tumefaction  of  the  vulva,  the  consequence  of  a larger 
supply  of  blood  being  determined  to  these  organs.  This  is  very  apparent 
not  only  in  the  human  female,  but  also  in  the  brute  creation.  It  is  very 
usual ; and  this,  too,  is  a good  symptom,  because  it  shows  that  there  is  a 
disposition  in  the  passages  to  become  relaxed  and  open,  as  well  as  in 
the  uterus  to  contract.  It  is  dependent  on  one  of  nature’s  unerring  laws. 
Some  physiologists  would'  teach  us  to  believe  that  dilatation  in  labour  is 
entirely  a mechanical  act — that  as  the  uterus  contracts  it  propels  the 
head  first  through  the  os  uteri,  by  dilating  it  mechanically,  then  through 
the  vagina,  and  lastly  through  the  external  parts,  solely  by  the  same 
forcible  distention.  It  is  evident  from  the  structure  of  the  organs  that  a 
mechanical  dilatation  to  such  a great  extent  never  could  take  place, 
unless  a corresponding  disposition  to  relax  were  given  them  at  the  same 
time;  and  therefore  we  must  consider  the  dilatation  of  the  passages  not 
entirely  dependent  on  mechanical  distention ; but  that  it  is  in  a great 
measure  to  be  referred  to  that  institute  of  nature,  which  induces  them  to 
become  relaxed  and  softened,  when  the  uterus  is  about  to  commence  con- 
traction. 

3rd.  The  third  indication  of  approaching  labour  is  drawn  from  the 
state  of  the  mind.  We  often  observe  that  many  days  before  any  painful 
sensation  is  experienced,  there  is  a degree  of  fidgetiness  or  anxiety  for 
the  result  of  the  case.  This  is  more  strikingly  marked  in  the  lower 
animal  than  in  the  human  subject.  A woman  has  reason  to  sustain  and 
guide  her ; she  is  confidently  impressed  with  reliance  upon  a Supreme 
Power ; she  has  the  opportunity  of  calling  to  her  aid  the  soothing  com- 
forts of  religion ; and  the  brute  possesses  none  of  these  advantages.  In 
our  common  domestic  animals — the  bitch,  the  cat,  and  others,  whom  we 
can  watch  narrowly  prior  to  the  commencement  of  parturition — we 
observe  that  a day  or  two  before  the  process  actually  begins,  they  appear 


92 


labour,  ( Symptoms.) 

in  great  distress  : their  cries  are  evidently  not  those  of  pain,  but— if  we 
may  allow  it  them — of  anxiety ; and  they  busy  themselves  in  preparing  a 
bed  to  which  they  may  retire,  when  their  time  comes.  The  same  mental 
distress  may  be  remarked  in  the  female  of  our  own  race,  modified  and 
controlled  by  reason,  fortitude  and  religion. 

The  symptoms  which  indicate  that  labour  has  actually  commenced  are, 
first,  irritability  of  the  rectum  and  the  bladder;  secondly,  nausea  and 
vomiting ; thirdly,  rigors  or  tremors  unattended  with  any  feeling  of  cold ; 
fourthly,  a sanguineous  discharge  flowing  out  of  the  vagina ; and  fifthly, 
painful  sensations.  These  are  enumerated  in  the  inverse  order,  in  regard 
to  their  importance  as  diagnostic  signs. 

1st.  The  frequent  inclination  to  pass  urine  and  faeces,  dependent  on 
irritability  of  the  bladder  and  rectum,  arises  from  the  contiguity  existing 
between  these  organs  and  the  os  uteri,  their  deriving  a portion  of  their 
nervous  supply  from  the  same  source,  and  the  consequent  sympathy, 
through  which  they  mutually  affect  each  other.  They  are  very  usual  symp- 
toms of  commencing  labour ; and  are  to  be  attributed  to  the  process  of 
dilatation  going  on  in  the  os  uteri.  A desire  to  evacuate  the  bladder  will 
perhaps  occur  every  ten  or  fifteen  minutes,  although  there  be  scarcely  any 
fluid  in  it.  Medicines  are  of  little  avail  in  this  species  of  strangury ; but 
the  feeling  mostly  disappears  as  soon  as  the  mouth  of  the  womb  is 
tolerably  well  dilated;  so  that  before  the  head  comes  to  occupy  the  pelvis, 
it  has  generally  ceased.  The  same  remark  may  be  made  with  regard  to 
the  tenesmus.  This  symptom  is  more  distressing  than  the  irritation  at 
the  neck  of  the  bladder,  and  it  may  sometimes  be  relieved  by  a simple 
demulcent  injection : if  the  patient  be  suffering  much  annoyance  from 
it,  and  the  labour  is  progressing  but  slowly,  a few  drops  of  laudanum 
may  be  added  to  the  enema  with  advantage. 

2nd.  Nausea  and  vomiting  very  frequently — indeed  almost  always — 
attend  on  the  dilatation  of  the  os  uteri ; and  we  have  opportunities  con- 
stantly afforded  us  of  remarking  that  these  two  actions  bear  to  each  other 
the  relation  of  cause  and  effect.  It  is  by  no  means  unusual  to  find,  when 
the  os  uteri  is  rigid  during  the  first  stage  of  labour — when  it  evinces  little 
disposition  to  dilate  or  relax — when  this  state  has  continued  for  hours, 
and  when  very  little  progress  has  been  made  in  the  interval,  even  although 
the  pains  may  have  been  both  frequent  and  strong ; — that  on  a sudden 
attack  of  vomiting  supervening,  not  referable  to  any  external  cause,  a 
favourable  change  is  speedily  produced  in  the  uterine  mouth ; — it  has 
become  softened,  relaxed,  and  is  dilated;  and  the  process  goes  on  from 
that  time  with  comparative  rapidity.  Hence  vomiting  at  the  early  part 
of  labour  has  been  looked  upon  as  a good  symptom.  And  it  has  even 
been  recommended,  in  cases  rendered  lingering  by  rigidity  of  this  organ, 


93 


labour,  (Symptoms.) 

to  give  emetics  for  the  purpose  of  exciting  sickness,  under  the  impression 
that  the  act  of  vomiting  was  the  cause  of  the  relaxation  taking  place.  It 
is  not  the  cause  but  the  effect  of  that  relaxation ; so  that  the  artificial 
production  of  vomiting  is  not  followed  by  the  good  anticipated : emetics 
are,  now,  indeed  seldom  had  recourse  to  with  the  view  of  forwarding  the 
dilating  process ; although  nauseating  doses  of  antimony  are  sometimes 
employed  with  beneficial  results. 

The  matter  ejected  under  this  attack  of  vomiting  is  merely  what  the 
patient  has  lately  taken  into  the  stomach,  mixed  with  the  healthy  secre- 
tions of  that  viscus,  and  perhaps  with  a little  bile.  The  effort  itself  is  not 
attended  with  much  straining ; it  is  more  inconvenient  than  painful.  It 
seldom  lasts  any  length  of  time : — there  are  a few  paroxysms,  and  then 
the  affection  ceases.  Sometimes,  however,  it  will  continue  to  distress  and 
harass  the  patient  for  many  hours.  In  such  cases  it  may  perhaps  be 
dependent  on  a deranged  state  of  the  stomach  itself,  or  some  other  cause, 
besides  the  sympathy  existing  between  that  viscus  and  the  os  uteri.  The 
exhibition  of  an  effervescent  draught,  with  five  or  six  minims  of  laudanum, 
will  then  be  found  the  most  serviceable  as  well  as  grateful  medicine.  But 
in  ordinary  cases  no  remedies  will  be  required. 

Vomiting  at  the  commencement  of  labour,  then,  may  be  regarded  in  a 
favourable  light  rather  than  otherwise,  as  indicative  of  the  softening  process 
going  on  in  the  os  uteri.  But  it  behoves  us  to  discriminate  most  carefully 
this  kind  of  vomiting  from  that  which  takes  place  under  protracted  labour, 
— long  after  the  first  stage  has  terminated,  and  when  the  system  is  worn 
out  and  exhausted, — which  indeed  is  one  of  the  very  worst  signs  we  can 
observe.  There  is  not  much  probability  that  a mistake  should  be  made 
in  this  particular  ; — the  one  appears  early  in  the  labour ; the  other  most 
likely  after  the  patient  has  been  in  pain  a great  many  hours ; — accom- 
panying this  there  are  no  symptoms  of  exhaustion ; the  woman  is  in  good 
spirits,  the  pulse  is  not  much  accelerated,  and  the  countenance  is  not 
dejected  ; — with  the  other  there  appear  progressive  symptoms  of  urgent 
distress,  which  will  hereafter  be  especially  enumerated.  The  matter 
ejected  from  the  stomach  would  also  be  a guide,  if  any  doubt  existed.  In 
the  first  kind  it  consists  of  what  the  patient  has  last  taken  mixed  with  the 
natural  secretions ; when  it  is  the  effect  of  exhaustion  it  is  a deranged 
secretion — and  this  is  sometimes  formed  in  astonishingly  large  quantities ; 
— and  in  the  worst  cases  it  is  foetid,  dark  in  colour,  of  a greenish  cast,  or, 
like  the  matter  vomited  in  the  last  stage  of  typhus  fever,  possessing  some- 
what the  appearance  of  coffee  grounds. 

3rd.  Another  symptom  frequently  accompanying  the  commencement  of 
labour  is  the  occurrence  of  shivering,  or  tremors  unattended  with  any 
sensation  of  cold.  This  also  is  dependent  on  the  opening  of  the  os  uteri. 


94 


labour,  ( Symptoms. ) 

Such  rigours  are  seldom  distressing ; the  patient  pays  but  slight  regard  to 
them;— she  perhaps  feels  a little  chilly  or  shivers  in  a trifling  degree,  and 
she  may  experience  many  cold  fits  ; but  when  the  os  uteri  is  dilated  they 
disappear.  They  are  neither  connected  with  any  irregular  arterial  action, 
nor  with  pain  in  the  head  or  other  bad  symptom.  Sometimes,  indeed, 
they  are  sufficiently  intense  to  shake  the  bed  on  which  she  lies,  and  cause 
her  teeth  to  chatter  as  if  she  were  in  the  cold  stage  of  an  ague  fit ; and 
although  she  complains  of  being  very  much  chilled,  the  surface  may  be 
warmer  than  natural.  It  is  scarcely  necessary  to  use  any  other  means 
than  to  add  an  extra  covering  to  her  person,  and  exhibit  any  warm  diluent 
that  she  fancies. 

This  simple  shivering  must  be  distinguished  from  that  state  in  which 
the  frame  is  violently  agitated,  and  which  is  a species  of  convulsions  of 
the  most  dangerous  character,  that  will  come  under  consideration  in  a 
subsequent  part  of  this  work. 

4th.  The  next  symptom  to  be  noticed,  is  a discharge  from  the  vagina, 
of  a glairy  character,  tinged  with  blood,  technically  termed,  in  the  lan- 
guage of  the  lying-in  room,  a shew.  It  consists  of  an  increased  secretion 
from  the  vaginal  surface,  mixed  with  the  gelatinous  mucus  which  had 
previously  blocked  up  the  uterine  neck,  and  which  is  allowed  to  escape 
when  the  os  uteri  opens ; and  of  blood  poured  out  from  those  small  ves- 
sels of  the  os  and  cervix  uteri,  which  ran  into  the  deciduous  membrane, 
and  which  are  rendered  patulous  by  the  separation  of  that  membrane,  as 
soon  as  the  dilatation  of  the  womb  commences. 

This  is  a stronger  symptom  of  labour  having  commenced  than  any  I 
have  yet  mentioned.  When,  indeed,  this  “ shew”  takes  place  at  the  full 
period  of  pregnancy,  or  near  it, — especially  if  it  be  attended  with  periodical 
pains> — we  may  be  almost  certain,  even  before  we  make  an  examination, 
that  the  process  has  actually  begun.  A considerable  loss  of  blood  towards 
the  close  of  pregnancy  will  be  sometimes  called  by  the  same  name. 
Such  hsemorrhages,  however,  are  by  no  means  to  be  regarded  as  indica- 
tions of  parturition,  unless  there  be  observed  mixed  in  the  discharge  the 
glairy  gelatine  that  had  before  occupied  the  cervix  uteri. 

5th.  But  of  all  the  symptoms  announcing  the  access  of  labour,  pain  is 
the  most  prominent.  This  is  produced  by  the  contraction  of  the  uterine 
fibres,  and  is  referred  from  the  uterine  region  to  the  loins,  to  the  upper 
part  of  the  sacrum  and  the  inner  side  of  the  thighs.  Labour-pain  is 
merely  the  external  evidence  of  uterine  action  ; and  the  two  phrases  are 
used  synonymously  as  well  by  all  writers,  as  teachers  of  obstetric  medi- 
cine. The  sensation  of  pain  is  occasioned  partly  by  the  sensitiveness  of 
the  uterus  itself,  partly  by  the  resistance  offered  to  the  parietes  of  the 
organ  by  the  uterine  contents,  during  contraction,  and  partly  by  the 


95 


labour,  ( Symptoms. ) 

pressure  of  some  part  of  the  ovum  against  the  os  uteri  and  vagina  under 
the  process  of  dilatation.  So  that  it  has  three  sources — one  dependent  on 
the  simple  action  which,  like  the  spasmodic  contraction  of  muscles,  is 
attended  with  suffering — another,  that  of  opposed  propulsion — and  the 
third,  that  of  distention  of  the  passages.  As  a general  principle,  it  may 
be  said  that  the  stronger  the  uterus  acts  the  greater  is  the  pain.  In  some 
women  painful  sensations  accompany  the  very  first  commencement  of 
dilatation,  before  the  os  uteri  has  attained  a diameter  sufficient  to  admit 
the  point  of  the  finger : in  other  instances,  the  organ  will  have  been  opened 
to  a considerable  extent  before  any  pain  is  experienced  ; so  that  labour  has 
made  great  progress  unobserved  and  unnoticed.  These  are  the  cases  in 
which  it  is  supposed  that  the  whole  process  has  been  completed  by  the 
effect  of  three  or  four  pains.  We  cannot  imagine  that  such  complicated 
actions  could  be  perfected  by  so  slight  an  effort ; and  we  have  proof  to 
the  contrary  daily  presented  to  our  observation.  The  explanation  is  easy, 
on  the  ground  that  dilatation  has  been  accomplished  without  any  sensation 
of  pain ; and  that  the  expulsive  efforts  alone  have  been  attended  with  suf- 
fering. 

Uterine  action,  and  therefore  labour-pains,  may  be  suspended  or  removed 
by  many  causes : opiate  medicines  taken  into  the  stomach,  injected  into  the 
rectum,  or  rubbed  upon  the  surface  of  various  parts  of  the  body,  will 
usually  abate  the  contractions  in  a greater  or  less  degree.  Passions  and 
emotions  of  the  mind,  as  fright  or  sudden  surprise,  but  especially  those  of 
a depressing  character,  such  as  deep  grief,  or  more  transient  sorrow,  will 
also  produce  the  same  effect.  Even  so  trifling  a circumstance  as  a 
stranger  entering  the  room  when  the  patient  expected  her  own  attendant, 
has  been  known  to  put  a stop  to  labour,  in  the  midst  of  its  most  active 
operations,  and  to  suspend  it  for  many  hours.  It  is  principally  on  this 
account  that  we  are  careful  to  prevent  a woman  in  labour  becoming  sud- 
denly acquainted  with  any  news  that  is  likely  to  shock  her. 

Labour-pains  are  not  constant,  but  periodical ; they  intermit  with  inter- 
vals of  ease,  as  the  contractions  alternate  with  relaxations.  When  the 
uterus  is  inactive,  there  is  neither  any  pressure  against  its  contents,  nor 
any  forcing  of  them  through  the  os  uteri,  and  the  painful  sensations  for 
the  time  cease. 

At  the  commencement  there  is  merely  a feeling  of  uneasiness  ; and  when 
active  pains  first  begin,  they  are  short,  weak,  and  occur  at  long  intervals ; 
by  degrees  they  become  more  frequent,  longer,  and  stronger;  till  towards 
the  end  of  the  birth,  there  is  one  continued  effort  at  expulsion,  lasting,  per- 
haps, for  three  or  four  minutes  uninterruptedly. 

The  contractions  of  the  uterus  are  attended  with  different  sensations,  as 
also  with  a different  expression,  of  suffering  at  the  different  periods  of 


96 


labour,  ( Spurious  Pains.) 

labour.  Those  pains  which  depend  on  the  dilatation  of  the  os  uteri  are 
described  by  the  woman  as  being  of  a grinding  or  cutting  character. 
They  are  accompanied  by  a moaning  noise : if  the  patient  be  walking 
about  the  room,  she  will  rest  on  her  attendant’s  arm,  bend  herself  a little 
forward  for  a few  seconds,  utter  a subdued,  grumbling  noise,  and  then 
resume  her  exercise ; or,  if  she  be  sitting  in  a chair,  she  will  shrink,  as  it 
were,  into  a smaller  compass,  press  the  elbows  of  the  chair  with  some 
degree  of  force,  give  utterance  to  the  same  kind  of  moaning  sound ; and 
gradually  stretch  herself  out  again.  When,  however,  dilatation  has  gone 
on  to  such  an  extent  as  that  some  portion  of  the  contents  of  the  uterus  is 
propelled  through  the  mouth  low  down  into  the  vagina,  the  pains  become 
of  a forcing  nature ; and  the  expression  attending  them  is  very  different 
from  that  just  described.  Under  these  expulsive  pains  the  breath  is  held 
in,  and  the  patient  forces  down  and  strains  as  though  she  were  passing 
hardened  fceces.  She  gives  no  audible  evidence  that  she  is  in  pain,  or 
perhaps  she  will  make  the  smothered  noise  which  is  usually  attendant  on 
a great  effort ; until  towards  the  close  of  the  paroxysm,  when  an  expres- 
sion of  more  acute  suffering  escapes  her.  And  when  the  head  is  resting 
on  the  perineum,  distending  the  external  structures,  and  just  about  to  pass 
out,  she  cannot  restrain  herself  from  giving  vent  to  a loud  shriek,  or  kind 
of  wild  cry. 

Spurious  Pains. — But  the  presence  of  pain,  even  if  it  be  periodical,  is 
not  always  symptomatic  of  labour  having  begun ; for  towards  the  end  of 
gestation,  women  are  subject  to  pains  in  the  loins  and  bowels,  simulating 
true  labour-pains  in  some  respects,  but  not  connected  in  any  way  with 
uterine  action  : hence  they  are  called  spurious , or  false  pains.  Sometimes 
they  are  confined  in  their  situation,  at  others  they  are  erratic ; sometimes 
they  return  at  tolerably  certain  intervals ; more  frequently  they  are  very 
irregular  in  their  recurrence.  They  are  often  connected  with  dyspeptic 
symptoms,  and  sometimes  attended  with  involuntary  spasms  of  the  dia- 
phragm and  abdominal  muscles,  which  cause  the  woman  to  bear  down 
and  believe  herself  in  labour.  Occasionally,  also,  a copious  watery  secre- 
tion from  the  glands  of  the  os  uteri  occurs,  so  as  to  give  an  idea  that  the 
membranes  of  the  ovum  have  broken ; at  other  times  an  involuntary  gush 
of  urine  takes  place  under  the  pains,  which  has  often  been  mistaken  for 
the  liquor  amnii.  If  it  be  urine  that  passes,  it  may  easily  be  distin- 
guished by  the  odour;  if  a secretion  from  the  glandulae  Nabothi,  it  will  be 
observed  to  dribble  away  slowly,  rather  than  to  be  evacuated  with  a sud- 
den burst. 

False  pains  generally  come  on  at  night ; and  not  unfrequently  they  will 
annoy  the  patient  for  weeks  before  the  commencement  of  real  labour, 


97 


labour,  ( Spurious  Pains.) 

harassing  her  much  by  their  severity,  and  preventing  her  obtaining  any 
sound,  refreshing  sleep.  At  others,  they  appear  only  a few  hours  prior  to 
the  accession  of  uterine  action ; and  in  the  principal  number  of  instances 
they  are  wanting  altogether.  They  are  more  frequently  met  with  in  pri- 
mary pregnancies  than  afterwards. 

Causes. — Both  the  seat  and  causes  of  false  pains  are  very  various. 
They  may  be  situated  in  any  of  the  pelvic  or  abdominal  viscera,  or  in 
any  of  the  muscles  of  the  lower  half  of  the  trunk.  Thus  the  iliaci  interni, 
the  psos3,  the  abdominal,  or  the  external  muscles  of  the  back,  may  any  of 
them  be  affected  with  spasm,  consequent  on  too  long  a walk,  or  over  exer- 
tion, or  fatigue  of  any  kind  ; and  these  pains  are  not  unlike  the  throes  of 
parturition.  Organic  disease  of  the  kidneys  or  bladder,  or  a prolapsed 
state  of  the  latter  viscus  below  the  cervix  uteri  may  also  occasion  the 
same  distress.  But  the  most  frequent  cause  is  irritation  existing  in  the 
lower  bowels,  or  an  irregularity  in  the  action  of  the  intestinal  canal 
throughout.  Diarrhoea,  the  evolution  of  a large  quantity  of  gas,  and  more 
particularly  constipation,  are,  of  all  the  many  causes,  those  to  which  false 
pains  may  be  most  usually  traced. 

j Diagnosis. — It  is  only  in  sensation,  however,  that  spurious  pains  bear 
any  affinity  to  those  of  parturition.  They  differ  in  their  seat,  in  the  irre- 
gularity of  their  return  and  duration,  and  in  their  intensity  not  progres- 
sively increasing;  moreover,  they  are  seldom  attended  by  any  of  the  other 
symptoms  which  usually  accompany  the  pains  of  labour.  False  pains, 
then,  may  be  distinguished  by  their  situation:  instead  of  commencing  at 
the  lower  part  of  the  loins,  and  being  extended  to  the  abdomen  and  thighs, 
they  are  probably  felt  higher  up  in  the  back,-  or  towards  one  or  other 
side ; — by  their  shifting  their  position  : it  is  seldom  that  they  are  constant 
to  one  spot,  but  mostly  erratic ; — but  they  may  especially  be  known  by 
the  length  of  their  duration  and  their  irregular  returns.  Thus  true  pains 
at  the  beginning  of  labour  are  short,  weak,  and  the  intervals  between 
them  long ; and  they  increase  in  frequency  and  intensity  as  the  process 
advances  : false  pains,  on  the  contrary,  observe  no  kind  of  regularity  either 
in  regard  to  the  periods  of  their  return,  or  to  their  progressively  becoming 
more  frequent  or  severe. 

But  the  best  criterion  by  which  we  can  distinguish  true  from  false  pains 
is  an  examination  of  the  uterus  externally  through  the  parietes  of  the 
abdomen,  and  internally  by  the  vagina.  If  the  pains  be  those  of  uterine 
contraction,,  our  hand  placed  upon  the  abdomen  will  detect  the  uterine 
structure  becoming  harder,  firmer,  denser,  and  somewhat  smaller,  with 
each  pain,  until  it  arrives  at  its  acme ; it  then  more  or  less  slowly  relaxes, 
and  acquires  the  same  degree  of  flaccidity  which  it  possessed  when  the 
hand  was  first  applied. 


98 


labour,  ( Spurious  Pains.) 

Yet  it  is  not  in  every  case  where  the  abdomen  becomes  harder  under 
pain  that  uterine  contraction  is  the  cause ; for  it  not  unfrequently  happens 
that  the  alteration  so  perceptible  to  our  sensation  is  occasioned  by  spasm 
of  the  abdominal  muscles.  If  the  fibres  of  these  muscles  act  irregularly, 
and  embrace  the  uterus  closely,  there  is  communicated  to  the  hand  a 
deceptive  feeling  of  progressively  increasing  hardness,  as  though  it  were 
the  uterus  contracting ; and  it  is  almost  impossible  to  discriminate  between 
the  one  cause  of  pain  and  the  other.  But  an  examination  per  vaginam 
will  at  once  clear  up  the  difficulty.  If,  in  the  inquiry  thus  instituted,  we 
find  the  os  uteri  at  all  open — even  should  its  diameter  be  not  larger  than 
will  admit  the  point  of  the  finger — if  we  find  that  with  each  pain  its  edge 
becomes  stretched  like  a cord  around  the  membranes  which  are  pro- 
truded through  it — if  we  find  that  the  membranes  are  propelled  down- 
wards, and  become  tense  with  each  pain,  retreat  and  become  flaccid 
when  the  pain  goes  off — and  if  with  the  recession  of  the  membranes 
we  observe  that  the  os  uteri  also  regains  its  original  flaccidity,  we  may 
be  sure  that  the  tense  condition  is  produced  by  a propulsion  of  the  uterine 
contents,  and  this  can  only  be  effected  by  a contraction  of  the  uterine 
fibres ; so  that  such  pains  are  certainly  those  of  labour. 

But  if,  on  the  contrary,  we  discover  that  the  mouth  of  the  womb  is 
perfectly  close — that  there  is  no  attempt  at  dilatation — no  possibility  of 
introducing  the  finger  within  it,  and  yet  the  patient  is  complaining  of  vio- 
lent pain,  and  using  bearing-down  efforts,  we  may  be  equally  sure  that  the 
suffering  she  is  enduring  does  not  arise  entirely,  if  at  all,  from  uterine 
action.  Still  it  is  possible,  and  not  unlikely,  that  the  os  uteri  may  be 
opened  to  some  extent,  that  we  may  be  able  to  feel  the  presenting  part  of 
the  child ; and  the  pains,  notwithstanding,  may  be  spurious — active  labour 
may  not  have  come  on.  Even  here  we  may  distinguish  the  true  cause  by 
ascertaining  whether  with  each  paroxysm  the  disc  of  the  os  uteri  becomes 
tense,  and  whether  at  the  same  time  the  membranes  protrude.  If  there  be 
no  change  in  the  os  uteri,  even  although  it  will  readily  give  passage  to  the 
extremity  of  the  finger,  and  if  there  be  no  propulsion  of  the  membranous 
bag  when  the  pain  is  urgent,  that  pain  is  assuredly  not  the  result  of  uterine 
action. 

Whenever  any  doubt  exists,  it  is  necessary  that  these  examinations 
should  be  instituted, — first,  of  the  abdomen,  and  then  of  the  os  uteri,  in 
order  to  make  the  case  clear.  It  is  probable,  that  by  merely  laying  the 
hand  on  the  uterus  exteriorly  we  may  be  satisfied  that  it  is  not  uterine 
pain ; but  if  that  proceeding  does  not  bring  conviction,  it  is  right  gently 
and  delicately  to  insist  on  making  the  internal  examination.  The  woman 
may  object  to  this  examination  being  made;  but  the  information  we  gain 
by  this  simple  proceeding  is  so  useful,  may  save  so  much  anxiety  and 


99 


labours,  ( Classification  of) 

distress,  and  so  materially  regulates  our  practice,  that  if  deemed  abso- 
lutely necessary — and  unless  this  be  the  case,  indeed,  we  ought  not  to 
propose  it — the  point  should  never  be  given  up.  Many  a day  and  night 
have  been  spent  in  anxious  watching  over  a patient,  to  the  great  incon- 
venience of  the  practitioner,  to  the  destruction  of  his  rest  and  health,  and 
perhaps  to  the  detriment  of  his  professional  character,  when  there  was  not 
the  slightest  necessity  for  such  close  attendance,  simply  because  the  patient 
would  not  acquiesce  in  the  requisite  examination  being  made. 

Treatment . — Since  spurious  pains  are  so  distressing,  since  they  are 
producing  no  good,  and  since  they  may  so  undermine  the  patient’s  powers 
that  she  may  not  have  strength  enough  left  to  go  through  the  fatigues  of 
labour,  it  is  our  duty,  if  possible,  to  remove  them ; and  the  best  treatment 
for  that  object  is  rest  in  whatever  posture  is  most  easy,  acting  pretty  freely 
on  the  bowels,  and  the  exhibition  of  opiates,  either  by  the  mouth  or  by 
injection.  If  the  bowels  be  loaded,  as  is  most  usually  the  case,  opium  in 
the  first  instance  will  do  more  harm  than  good ; but  after  the  evacuation 
of  the  intestinal  canal,  that  drug  is  highly  useful.  Recourse  may  also  be 
had  to  opiate  liniments  applied  to  the  back,  thighs,  abdomen,  or  any  other 
part  where  the  pain  is  most  intense.  In  plethoric  habits,  or  if  there  be 
present  inflammatory  symptoms,  it  may  be  proper  to  take  blood  from  the 
arm  ; but  as  a general  principle,  bleeding  will  not  produce  permanent  alle- 
viation. 

In  first  pregnancies  spurious  pains  are  often  occasioned  by  the  rigidity 
of  the  abdominal  muscles,  which  do  not  yield  as  they  ought  to  the 
enlarging  womb.  The  best  means  of  relief  under  such  circumstances  will 
be  found  in  gentle  friction  with  some  emollient  application.  Care  must 
be  taken,  however,  that  this  practice  be  not  carried  beyond  proper  bounds; 
for  friction  over  the  abdomen  tends  to  produce  uterine  contraction,  and  I 
have  known  more  than  one  instance  in  which  liniments  rubbed  on  the  part 
in  pain  with  more  than  necessary  assiduity,  and  with  less  than  ordinary 
caution,  have  excited  the  premature  expulsion  and  consequent  loss  of  the 
foetus. 


CLASSIFICATION  OF  LABOURS. 

For  practical  purposes  labour  may  be  conveniently  divided  into  four 
classes : 

1st,  Natural, 

2nd,  Difficult, 

3rd,  Preternatural, 

4th,  Complex. 


100 


labours,  ( Classification  of.) 

The  first  class,  or  Natural  Labour,  admits  of  no  subdivisions;  and  it 
may  be  defined,  a case  in  which  the  head  of  the  child  presents; — in  which 
not  more  than  twenty-four  hours  are  occupied  from  the  commencement 
of  tru^  uterine  action  to  the  termination  of  the  process ; — in  which  nothing 
extraordinary  happens,  nothing  of  a dangerous  or  alarming  tendency 
supervenes  throughout  the  whole  conduct  of  the  case.  And  that  labour  is 
deemed  natural,  in  the  acceptation  of  the  term  which  I offer,  if  any  part 
of  the  head  present,  even  although  it  be  the  forehead  or  face  itself,  pro- 
vided all  the  circumstances  enumerated  concur. 

The  second  class — Difficult — is  divided  into  two  orders : 

Jl,  Lingering. 

B,  Instrumental. 

To  constitute  this  class,  also.,  it  is  necessary  that  the  head  should  present ; 
and  the  first  order  defines  those  labours  in  which,  under  a head  presenta- 
tion, more  than  twenty-four  hours  is  occupied  from  the  commencement  to 
the  termination  of  the  case ; but  in  which  there  is  no  necessity  for  instru- 
mental interference,  and  during  the  progress  of  which  no  dangerous 
symptoms  arise — nothing  calling  for  anxiety  occurs,  except  the  unusual 
lapse  of  time. 

The  second  order  of  this  class — instrumental — embraces  all  cases  of 
head  presentation  which  require  to  be  terminated  by  instruments.  It 
includes  two  species : 

a , those  cases  which  can  be  managed  by  the  use  of  instruments  per- 
fectly compatible  both  with  the  life  of  the  child  and  of  the  mother, 
as  well  as  the  safety  and  continuity  of  the  mother’s  structures ; such 
as  are  terminated  by  the  forceps  or  vectis. 

b,  those  in  which  we  are  compelled  to  have  recourse  to  instruments 
incompatible  either  with  the  life  of  the  child,  or  with  the  safety  and 
continuity  of  the  mother’s  structures — labours,  indeed,  which  are 
completed  by  cutting  instruments. 

Of  this  latter  species,  there  are  two  varieties — 

*,  some  in  which  the  instruments  are  applied  to  the  foetal  body ; as 
when  the  case  is  terminated  by  the  use  of  the  perforator. 

/3,  those  in  which  the  mother’s  structures  are  divided  by  the  scalpel,  or 
some  such  instrument,  as  in  the  Caesarean  or  Sigaultean  operations- 

The  third  class — Preternatural  Labours — or,  in  common  language, 
cross  births,  includes  all  cases  in  which  any  other  part  of  the  child’s  body 
than  the  head  presents— the  breech,  feet,  knees,  back,  belly,  sides, 
shoulders,  arms  or  hands.  In  this  class  we  recognise  two  orders— 


101 


labours,  ( Classification  of. ) 

A,  all  those  cases  in  which  the  lower  end  of  the  oval  formed  by  the 
doubled  foetal  body  offers  itself,  viz.  the  breech,  or  some  part  of  the 
inferior  extremities,  as  the  feet  or  the  knees. 

B,  those  others  in  which  neither  the  head,  breech,  nor  any  part  of  the 
lower  extremities  present.  Such  are  transverse  presentations,  to  which, 
indeed,  the  phrase  cross  births  ought  in  propriety  to  be  restricted  ; — 
breast,  abdomen,  side,  back,  shoulder,  neck,  elbow,  and  hand  pre- 
sentations. 

Into  the  fourth  class — Complex  Labours — may  be  admitted  all  those 
cases  which  cannot  be  referred  to  any  of  the  foregoing  divisions;  since 
there  are  peculiarities  appertaining  to  each  which  render  them  both 
complicated  and  embarrassing.  This  class  will  embrace  ten  orders, 
most  of  them  attended  with  danger,  and  all  with  irregularities. 

A.  Labours  complicated  with  dangerous  haemorrhage. 


B.  convulsions. 

C.  rupture  of  the  uterus. 

D.  lacerated  vagina. 

E.  ruptured  bladder. 

F.  descent  of  the  funis  before  the  head  or 

breech. 

G.  descent  of  one  or  both  hands  with  the 

breech. 

H.  syncope  unconnected  with  uterine  flood- 


ings. 

I.  Labours  in  which  monsters  are  produced. 

K.  Labours  complicated  with  purality  of  children. 

Three  circumstances  must  strike  the  attention  on  this  enumeration ; 
first,  that  there  are  a number  of  cases  assembled  together  in  one  class, 
without  their  possessing  any  affinity  to  each  other ; secondly,  that  some 
of  them  are  in  the  highest  degree  dangerous,  while  others  must  not  be 
considered  more  than  ordinarily  so ; and,  thirdly,  that  in  some  of  them 
the  danger  or  irregularity  is  referable  to  the  parent,  and  in  others  to  the 
child.  Thus,  in  cases  of  laceration  and  convulsions,  the  cause  is  to  be 
sought  in  the  system  of  the  mother;  but  where  the  funis  or  hand  descends 
by  the  side  of  the  head  or  breech,  the  irregularity  is  referable  to  the 
ovum,  and  the  cause  may  be  attributed  to  the  arrangement  of  the 
contents  of  the  uterine  cavity.  Each  of  these  orders  might  indeed  be 
considered  a separate  class ; but  I think  it  better  to  comprehend  them 
under  one  general  head,  in  order  to  prevent  a multiplication  of  classes, 
which  in  all  nosological  arrangements  must  be  both  inconvenient  and 
perplexing. 


102 


natural  labour,  {Stages.) 


NATURAL  LABOUR. 

Plates  XXII.,  XXIII.,  XXIV.,  XXV.,  XXVI.,  XXVII.,  XXVIII.,  XXIX. 

Stages  of  Labour. — Most  writers  agree  that  it  is  desirable,  for  the  pur- 
pose of  clearly  understanding  the  process,  to  divide  labours  into  certain 
parts  or  stages;  but  as  there  is  much  difference  in  the  classification 
adopted  by  different  teachers,  so  also  a diversity  has  obtained  in  the 
number  of  these  stages ; some  preferring  three,  as  Denman,  Hamilton, 
Blundell,  Thatcher,  and  most  modern  teachers;  others  four,  as  Merriman, 
Velpeau,  Romer  of  Zurich,  Bard  of  New  York;  and  others,  again,  five, 
as  Hogben,  Naegele,  and  the  German  school ; — all  these  stages  termi- 
nating on  the  removal  of  the  placenta.  I think  Denman’s  arrangement 
by  far  the  best  for  practical  purposes,  and  shall  therefore  describe  labours 
as  consisting  of  three  stages : the  first  terminating  with  the  opening  of  the 
os  uteri  to  its  full  extent,  the  rupture  of  the  membranes,  and  the  evacua- 
tion of  the  liquor  amnii ; the  second,  with  the  birth  of  the  foetus ; and  the 
third,  with  the  expulsion  of  the  placenta.  We  might  with  some  show  of 
reason  add  a fourth  stage,  considering  that  to  end  with  the  complete 
closure  of  the  uterine  vessels,  and  the  stoppage  of  every  chance  of 
haemorrhage:  but  as  this  last  might  continue  throughout  the  whole 
puerperal  month,  or  longer,  it  may  be  as  well  to  follow  the  more  ordi- 
nary usage,  and  to  regard  labour*  as  terminated  on  the  removal  of  the 
placenta. 

First  stage — dilatation  of  the  os  uteri. — The  first  stage, — that  which 
depends  upon  the  dilatation  of  the  os  uteri  from  its  perfectly  close  state  to 
that  of  its  full  diameter, — is  generally  the  longest,  the  most  uncertain  in 
time,  and  the  most  tedious  both  to  the  attendant  and  the  patient.  This 
stage  varies  exceedingly  in  every  feature,  as,  indeed,  do  all  the  others. 
There  is  a great  difference  observable  in  different  women,  and  in  the  same 
woman  at  different  labours,  in  the  state  of  the  os  uteri  soon  after  the  com- 
mencement of  the  process.  In  some  it  will  be  found  soft,  lax,  and  yield- 
ing,— though  not  dilated,  still  dilatable ; while  in  others  it  is  hard,  firm, 
rigid  and  unyielding, — not  allowing  itself  to  be  distended  at  all  by  the 
finger  any  more  than  a piece  of  hard  leather  would.  There  are  four 
chief  varieties  of  the  os  uteri,  during  the  first  stage  of  labour,  as  to  its 
character.  The  first  is  when  it  is  thick,  soft,  moist,  cool,  sensible  to  the 
touch — but  not  painfully  so, — having  very  much  the  feel  of  a piece  of 
thick,  wet,  chamois  leather.  The  second  variety  is  when  it  is  thick,  hard, 


!(% 


natural  labour,  ( First  Stage.) 

and  rigid ; perhaps  also  hot,  dry,  and  tender,  and  gives  a sensation  to  the 
finger  very  much  like  the  touch  of  a piece  of  cartilage.  Under  the  third 
variety,  the  os  uteri  is  thin,  soft,  moist,  cool,  and  not  painful,  its  edge  feel- 
ing like  a piece  of  moist  brown  paper ; and  so  thin,  that  through  the  sub- 
stance of  the  cervix  the  head  of  the  child  can  he  pretty  distinctly  felt. 
The  fourth  is  when  it  is  thin  also,  but  hard  and  rigid,  tender  or  not  accord- 
ing to  circumstances,  having  a glazed  feel,  with  its  edge  surrounding  the 
presenting  part  of  the  child,  and  tightly  embracing  it,  like  a piece  of  whip- 
cord. Under  one  or  other  of  these  varieties  we  shall  always  be  able  to 
arrange  each  state  of  the  os  uteri  soon  after  the  commencement  of  labour. 
It  may  be  regarded  as  most  likely  to  dilate  kindly,  when  it  possesses  a 
soft  thick  feeling,  like  a piece  of  wet  chamois  leather,  and  is,  as  it  were, 
chinked.  Certainly  either  of  the  two  soft  states  gives  a better  indication  of  a 
disposition  to  dilate,  than  those  which  are  rigid ; and  it  may  be  also  deemed 
least  inclined  to  give  way,  when  it  is  thin  and  hard,  and  when  the  head 
comes  down  into  the  pelvis  completely  covered  with  the  cervix  uteri, — 
the  circular  edge  resembling  whip-cord,  or  wire. 

Varieties  in  the  time  occupied  in  dilatation. — As  there  is  almost  every 
variety  in  the  state  of  the  os  uteri  at  the  commencement  of  labour,  so  also 
there  is  great  diversity  in  the  time  occupied  in  its  opening ; sometimes 
two  or  three  hours  only,  at  others  the  same  number  of  days,  are  consumed 
in  the  progress  of  the  first  stage ; and  the  os  uteri  of  the  same  woman 
will  differ  much  in  this  respect  in  her  different  labours. 

Variations  in  the  height  of  the  os  uteri. — We  also  find  the  os  uteri 
varying  exceedingly  in  situation  at  the  commencement  of  labour ; it  is 
sometimes  so  high,  that  we  can  scarcely  feel  it  when  the  finger  is  intro- 
duced, as  in  a common  examination ; and  at  others  it  is  so  low,  that  it  is 
met  with  just  within  the  vagina,  and  the  presentation  may  be  detected 
through  the  cervix.  A more  speedy  termination  may  be  expected,  cceteris 
paribus , when  the  head  has  descended  somewhat  into  the  cavity  of  the 
pelvis,  than  when  the  os  uteri  is  felt  nearly  at  the  brim  ; unless,  indeed, 
the  cervix  should  possess  the  thin,  glazed,  hard  feeling  that  I have  just 
described ; when  we  are  to  anticipate  a lingering  labour.  It  is  generally 
to  be  found  about  two  inches  from  the  vulva,  looking  backwards  to  the 
upper  joint  of  the  coxyx,  and  it  is  readily  discovered  by  the  fore  finger  of 
the  right  hand,  or,  at  any  rate,  by  the  first  two  fingers  of  the  left  hand 
introduced  into  the  vagina. 

Relative  progress  of  dilatation. — Again,  we  observe  that  the  first  part 
of  the  dilating  process  usually  goes  on  slower  than  the  after  part.  Thus, 
that  degree  of  dilatation  under  which  the  organ  acquires  the  diameter  of  a 
shilling, — sufficiently  large  to  admit  the  tips  of  two  fingers, — will  perhaps 
take  up  a longer  period  of  time  than  its  dilatation  from  that  small  size  to 


104 


natural  labour,  ( First  Stage. ) 

the  full  and  entire  dimension,  which  easily  allows  the  head  of  the  child  to 
pass  through  it.  This  partly  arises,  perhaps,  from  the  natural  disposition 
in  the  os  uteri  to  open  more  readily  after  it  has  acquired  a certain  diame- 
ter ; but  it  is  owing  also  in  some  degree  to  mechanical  action ; for  when 
it  has  become  expanded  to  such  an  extent  as  to  admit  the  membranous 
bag,  or  any  portion  of  the  child’s  head  to  occupy  its  aperture,  the  pro- 
truded part  acts  like  a wedge,  and  forcibly  distends  it.  The  cause,  how- 
ever, is  not  entirely  and  purely  mechanical,  for  it  depends  in  a great  mea- 
sure on  the  principle  of  vitality. 

Generally  speaking,  the  os  uteri  dilates  with  more  pain  and  difficulty, 
and  takes  a longer  time  in  the  process,  during  first  labours  than  subse- 
quently. This  is  by  no  means  a universal  remark,  although  we  usually 
observe  that,  when  women  have  had  a number  of  children,  the  dilatation 
proceeds  with  comparative  ease.  Denman  accounts  for  this  facility  by 
the  observation — “ We  may  presume  that  a part  which  is  accustomed  to 
perform  an  office,  or  undergo  a change,  acquires  a readier  disposition  to 
the  office  or  change,  according  to  the  number  of  times  it  has  performed 
that  office,  or  undergone  that  change.”* 

It  is  quite  impossible  that  we  can  give  even  a probable  guess  as  to  the 
time  which  any  particular  os  uteri  will  require  for  the  perfection  of  its 
dilatation ; for  sometimes  one  that  has  been  from  the  commencement  of 
the  labour  highly  rigid,  scarcely  showing  the  least  disposition  to  open, 
will  suddenly  become  relaxed,  and  rapidly  distend  its  circle  to  its  full 
dimensions;  while  at  another,  though  the  part  is  soft  and  flaccid,  the  pains 
will  altogether  subside  without  any  apparent  cause ; the  process  of  dilata- 
tion will  be  suspended,  and  the  labour  will  remain  stationary  for  hours, 
without  in  the  least  progressing. 

The  pain  experienced  during  the  first  stage,  although  not  so  intense  or 
acute  as  in  the  second,  is  still  more  difficult  to  bear;  and  is  also  borne 
generally  with  less  fortitude.  It  is,  as  I stated  before,  of  a different  kind 
from  the  pains  of  expulsion ; it  is  a feeling  as  if  some  inward  part  were 
being  torn,  or  rent  asunder.  Perhaps  it  is  not  altogether  in  consequence 
of  the  peculiar  sensations  experienced,  that  the  patient  does  not  endure 
these  early  pains  with  so  much  resignation  as  those  of  a more  expulsive 
character ; but  also  from  the  knowledge  which  she  has  gained,  either  by 
a previous  labour,  or  in  conversation  with  her  friends,  that  so  long  as  the 
“ grinding  ” pains  continue,  there  is  no  chance  of  a speedy  release ; but 
that,  as  soon  as  the  “ forcing  ” pains  come  on,  the  labour  may  quickly  be 
brought  to  a close ; and  every  next , she  thinks,  may  terminate  her  suffer- 
ings. As  soon  as  the  pains  become  changed  in  their  character,  hope  is 


* Inlrod.  to  Mid.,  chap,  ix.  see.  G. 


natural  labour,  {First  Stage.)  105 

infused,  fresh  spirits  are  instilled,  and  thus  the  patient’s  powers  are  sus- 
tained. 

If  the  labour  be  progressing  regularly,  the  pain  subsides  and  again  re- 
turns ; thus  intermissions  alternate  with  paroxysms  of  suffering ; and  if  the 
woman  be  in  other  respects  well,  and  in  good  spirits,  she  will  often  fall 
into  a dose,  and  obtain  a refreshing  slumber  during  the  intervals  of  uterine 
action : each  pain,  when  it  returns,  awakening  her  from  the  delicious  state 
of  oblivion  and  repose,  to  a fearful  consciousness  of  the  trials  she  has  to 
undergo. 

Rupture  of  the  membranes. — With  each  pain  the  membranes  are  more 
or  less  protruded  through  the  os  uteri,  so  that  they  become  tense,  and  the 
circle  of  the  dilated  mouth  is  drawn  tightly  around  them.  Plate  XXII. 
fig.  72,  shows  the  membranous  cyst  passing  through  the  mouth  of  the 
womb,  and  occupying  a portion  of  the  vagina.  In  the  interval  of  pain, 
when  the  uterus  exerts  no  pressure  from  above,  the  membranes  retreat, 
become  flaccid,  and  are  scarcely  to  be  felt ; and  as  there  is  little  or  no 
water  then  intervening  between  the  finger  and  the  person  of  the  child,  its 
presenting  part  can  usually  be  distinctly  discerned.  Such  a state  of  alter- 
nate protrusion  and  retrocession  of  a part  of  the  membranous  cyst  continues 
an  uncertain  time;  when  under  one  of  these  painful  contractions  the  mem- 
branes will  burst,  the  liquor  amnii  will  be  evacuated,  and  the  head  of  the 
child  will  come  to  bear,  with  each  paroxysm,  against  the  internal  surface 
of  the  os  and  cervix  uteri.  On  the  breaking  of  the  membranes,  the  first 
stage  of  labour  has  terminated. 

Variations  in  the  period  when  the  membranes  rupture. — I ha^e  thus 
described  the  progress  of  a labour  prior  to  the  rupture  of  the  membranes, 
taking  it  for  granted  that  the  liquor  amnii  will  not  be  evacuated  until  the 
os  uteri  is  dilated  to  nearly  its  full  extent ; but  these  two  occurrences, — the 
full  dilatation  of  the  os  uteri,  and  the  rupture  of  the  membranous  cyst, — 
are  not  always  found  in  practice  to  correspond  with  regard  to  time : for 
sometimes  the  membranes  break  before  the  aperture  is  dilated  even  to  the 
size  of  a shilling;  while  at  others  they  protrude  considerably  through  that 
organ  before  they  rupture ; the  head  of  the  child  having  descended  so  low 
as  to  occupy  the  cavity  of  the  pelvis,  and  the  os  uteri  having  been  widely 
open  for  some  considerable  time.  Generally  the  membranes  burst  when 
the  mouth  of  the  womb  has  become  dilated  to  a size  sufficient  to  admit 
the  hand ; and  we  may  presume  that  where  such  a degree  of  dilatation 
exists,  the  next  two  or  three  pains  will  expel  the  head  entirely  through  its 
orifice. 

According  as  the  membranes  are  more  or  less  rigid,  and  the  mouth  of 
the  womb  more  or  less  yielding,  will  be  the  time  consumed  previously  to 
the  discharge  of  the  waters.  When  the  os  uteri  is  soft,  and  the  mem- 
14 


106 


natural  labour,  ( Second  Stage.) 

branous  bag  tough,  it  will  probably  be  long  before  this  evacuation  takes 
place ; but  when  it  is  rigid,  and  the  membranes  are  thin  and  tender,  they 
generally  break  early.  The  period  at  which  the  membranes  rupture, 
therefore,  will  not  only  depend  upon  their  own  toughness  or  tenuity,  but  it 
will  also  be  regulated  by  the  pressure  which  the  edge  of  the  os  uteri  exerts 
on  them  while  they  are  protruded  through  it.  The  more  lax  is  the  os 
uteri,  the  less  is  the  compression  on  the  extruded  portion  of  the  cyst,  be- 
cause it  then  distends  to  the  power  operating  from  within : but  if  it  be 
rigid,  the  pressure  is  great;  for  then  the  inner  margin  closely  and  strongly 
embraces  the  tense  membranes  all  around,  producing  by  its  very  resist- 
ance a deep  circular  groove;  and  thus  disposing  the  bag  to  premature 
laceration. 

It  is  desirable  in  practice  to  preserve  the  membranous  bag  entire  as 
long  as  possible ; or,  at  least,  until  it  has  performed  the  whole  of  the  office 
destined  for  it  by  nature;  namely,  the  dilatation  of  the  os  uteri, the  vagina, 
and  somewhat  of  the  external  parts.  When  the  membranes  appear  exter- 
nally to  the  vulva,  indeed,  we  may  suppose  that  they  have  then  effected 
all  the  good  that  can  be  expected  from  them;  that  their  remaining  entire 
may  possibly  be  retarding  the  labour;  and  we  may  in  that  case  ven- 
ture to  rupture  them,  provided  the  head  present.  But  it  is  one  of  the  first 
axioms  to  be  learned  in  obstetric  practice,  not  officiously  or  unnecessarily 
to  destroy  the  cyst,  so  long  as  any  advantage  can  b.e  gained  by  its  dilating 
powers. 

■ 

Second  stage — Passage  of  the  Fcetus  through  the  Pelvis. — From  the 
foregoing  remarks  it  may  be  gathered  that,  after  an  uncertain  time,  the 
os  uteri  becomes  fully  dilated;  the  membranes  burst;  the  liquor  amnii 
is  evacuated,  generally  in  a full  stream ; and  the  second  stage  of  labour 
commences. 

Modes  in  which  the  vertex  presents. — The  passage  of  the  head  through1 
the  brim  of  the  pelvis  forms  the  first  part  of  the  second  stage.  It  is  pro- 
bable, indeed  that  the  head  may  have  descended  considerably  into  the 
cavity  before  the  waters  flow  away;  but  it  is  also  possible  that  it  may 
scarcely  have  engaged  itself  even  in  the  brim,  when  this  crisis  in  the  pro- 
cess occurs.  It  has  been  already  shown,  that  of  all  the  points  of  the 
head,  the  vertex  is  most  usually  presenting ; and  it  has  also  been  proved 
that  this  is  a most  wise  and  beneficent  provision  of  nature,  because  in  that 
position  the  foetal  skull  will  pass  through  an  aperture  of  less  dimensions 
than  in  any  other.  The  vertex  then  depending,  there  are  eight  different 
directions  in  which  the  head  may  be  placed,  requiring  our  consideration, 
in  a view  to  practical  utility.  The  first  is  with  the  face  inclining  to  the 
right  ilium ; the  right  ear  being  behind  the  symphysis  pubis ; the  left  ear 


Pi.xxn. 


f'' iriclairS,  Lit/; 


107 


natural  labour,  {Second  Stage.) 

towards  the  spinal  column ; and  the  occiput  inclined  to  the  left  ilium. 
Plate  XXII.  fig.  73.  The  second  is  the  reverse  of  this  position ; the  face 
inclines  to  the  left  ilium ; the  occiput  to  the  right  ilium ; the  right  ear  lies 
towards  the  promontory  of  the  sacrum  ; the  left  ear  behind  the  symphysis 
pubis.  Plate  XXII.  fig.  74.  The  third  mode  is,  when  the  head  is  placed 
diagonally,  the  face  looking  to  the  right  sacro-iliac  synchondrosis ; the 
right  ear  to  the  right  groin ; the  left  ear  to  the  left  sacro-iliac  synchon- 
drosis; and  the  occiput  behind  the  left  groin.  Plate  XXIII.  fig.  75.  The 
fourth  position  is  the  reverse  of  this  again,  where  the  face  is  placed  against 
the  left  sacro-iliac  synchondrosis  ;■  the  occiput  behind  the  right  groin ; the 
right  ear  against  the  right  sacro-iliac  synehondrosis ; and  the  left  ear 
behind  the  left  groin.  Plate  XXIII.  fig.  76.  The  fifth  position  is  where 
the  face  is  looking  towards  the  right  groin ; the  occiput  to  the  left  sacro- 
iliac synchondrosis ; the  right  ear  to  the  left  groin ; and  the  left  ear  to  the 
right  sacro-iliac  synchondrosis.  Plate  XXIII.  fig.  78.  The  sixth  position 
is  where  this  is  reversed,  the  face  looking  towards  the  left  groin ; the  occi- 
put to  the  right  sacro-iliac  synchondrosis ; the  right  ear  to  the  left  sacro- 
iliac synchondrosis;  and  the  left  ear  to  the  right  groin.  Plate  XXIV. 
fig.  77.  The  seventh  is  where  the  head  attempts  the  passage  with  the  fore- 
head immediately  against  the  promontory  of  the  sacrum;  the  right  ear  to 
the  right  ilium  ; the  left  ear  to  the  left  ilium ; and  the  occiput  behind  the 
symphysis  pubis.  Plate  XXIV.  fig.  79.  And  the  eighth,  where  this  posi- 
tion is  reversed,  the  occiput  being  exactly  against  the  promontory  of  the 
sacrum ; the  forehead  impinging  on  the  symphysis  pubis ; the  right  ear  to 
the  left  ilium ; the  left  ear  to  the  right  ilium.  Plate  XXIV;  fig.  80. 

Comparative  frequency  of  the  various  modes  of  vertex  presentation. — 
Of  these  presentations,  the  first  four  are  by  far  the  most  frequent ; — that 
is,  when  the  face  either  looks  directly  to  one  ilium  or  the  opposite ; or 
diagonally  to  one  sacro-iliac  synchondrosis  or  to  the  other.  Under  either 
of  these  position s?- the  natural  inclination  of  the  head  is  to  descend  into  the 
pelvic  cavity  in  the  same  direction  in  which  it  cleared  the  brim  until  it 
reaches  ihe  outlet,  and  then  to  turn  with  the  face  into  the  hollow  of  the 
sacrum,  and  the  occiput  under  the  arch  of  the  pubes,  the  face  being 
expelled,  sweeping  the  perineum.  When  such  is  the  original  situation 
of  the  head,  the  labour  is  more  easily  accomplished  than  under  any 
other.  It  is  supposed  that  the  face  is  more  commonly  inclined  towards 
the  right  side  than  the  left ; and  this  accords  with  my  own  more  recent 
observations. 

Of  the  next  four  presentations,  the  fifth  and  sixth  are  the  most  frequent, 
viz.  where  the  face  is  looking  diagonally  to  one  or  other  groin,  and  the 
occiput  to  one  or  other  sacro-iliac  synchondrosis.  These  are  not  very 
frequent  cases,  but  they  are  occasionally  met  with,  and  the  head  is  seldom 


108  natural  labour,  [Second  Stage.) 

so  speedily  expelled  as  in  either  of  the  first  four.  In  these  situations,  the 
natural  inclination  of  the  head  is  to  pass  down  diagonally  till  it  comes  to 
the  outlet  of  the  pelvis,  and  then  to  turn  with  the  face  under  the  arch  of 
the  pubes  and  the  occiput  into  the  hollow  of  the  sacrum.  Much  more 
room  is  required  for  the  exit  of  the  skull  with  the  face  forwards,  than 
when  it  is  thrown  back  into  the  sacral  curve;  because  its  general  figure  is 
then  not  so  well  adapted  to  the  pelvic  cavity ; but  especially  because  the 
expanded  brow  does  not  so  easily  insinuate  itself  between  the  rami  of 
the  pubic  arch  as  the  more  conical  vertex  does.  For  this  reason,  the 
occiput  is  pressed  more  powerfully  backwards  before  expulsion  takes 
place ; the  coxyx  is  put  more  upon  the  stretch,  and  the  perineum  is  also 
more  extended. 

Yet,  although  the  natural  inclination  of  the  face  would  be  to  appear 
under  the  pubes  in  its  exit  when  it  was  originally  directed  to  either  groin,  it 
is  by  no  means  uncommon  for  the  head,  in  its  passage  through  the  pelvis, 
to  turn  with  the  face  into  the  sacral  cavity,  and  to  be  expelled  in  the  same 
manner  as  though  the  face  had  from  the  commencement  been  inclined 
laterally  or  diagonally  backwards.  These  irregular  positions  of  the  head 
are  frequent  causes  for  the  necessity  of  instrumental  interference. 

The  seventh  and  eighth  cases  of  vertex  presentations — where  the  face 
attempts  the  passage,  being  placed  directly  against  the  promontory  of  the 
sacrum,  or  above  the  symphysis  pubis — are  the  most  infrequent  of  all  the 
eight ; they  are  so  rare,  that  some  practitioners  of  considerable  experience 
tell  us  they  never  met  with  them.  Naegele*  and  other  German  authors 
deny  the  existence  of  such  a case ; and  Campbellf  doubts  the  possibility  of 
its  occurrence. 

As  in  the  early  part  of  this  work  it  was  demonstrated  that  the  foetal 
cranium,  from  occiput  to  forehead,  measures  four  inches  and  a half,  while 
the  sacro-pubal  diameter  of  the  pelvis  at  the  brim  possesses  only  four 
inches  of  clear  available  space ; it  is  evident  that,  although  the  head 
might  present  in  the  seventh  or  eighth  position,  it  cannot  enter  the  pelvis 
in  either  of  those  directions.  Before,  then,  it  can  engage  in  the  superior 
strait,  it  is  compelled  to  turn,  with  the  face  somewhat  towards  the  right 
or  the  left  side.  I have  certainly  never  been  called  upon  to  deliver  by 
instruments  when  the  head  occupied  either  of  the  unfortunate  situations 
now  under  discussion ; but  I have  known  them  to  obtain  at  the  commence- 
ment of  labour;  and  I have  traced  the  head  make  a turn  with  the  face  to 
one  or  other  side,  being  forced  into  that  position  by  the  strength  of  the 
uterine  contractions,  in  an  analogous  manner  to  the  turn  effected  in  all 

* Essay  on  the  Mechanism  of  Parturition.  By  Rigby,  preface,  p.  16. 

t Introduction  to  Midwifery,  p.  244. 


pi.xrrti. 


Fiff.  7o. 


Sinclair's  Jlith'- 


Fi&.  77. 


Fig,  7# . 


Fig.  70. 


Pl.X&TY. 


109 


natural  labour,  ( Second  Stage. ) 

natural  labours,  when  it  is  on  the  point  of  being  expelled  through  the  out- 
let. I think,  therefore,  the  assertion,  that  such  a presentation  never  occurs, 
or  is  impossible,  far  too  general  and  sweeping;  and  a case  detailed  by  Mr. 
Radford*  proves  that  my  opinion  is  correct. 

Phenomena  observed  during  the  second  stage. — When  the  mouth  of  the 
womb  is  entirely  dilated — whether  that  occurrence  have  taken  place  pre- 
viously to,  or  after  the  rupture  of  the  membranes — it  becomes  as  it  were 
obliterated,  the  vaginal  and  uterine  cavities  form  one  continuous  canal, 
and  the  division  between  them  is  not  easily  discernible  until  after  the  child’s 
expulsion.  The  discharge  of  the  liquor  amnii  is  usually  followed  by  a 
respite  from  pain,  of  rather  longer  duration  than  had  been  experienced  for 
some  time  before ; but  when  the  uterine  contractions  return,  they  are 
mostly  increased,  both  in  length  and  strength ; they  are  more  forcing,  and 
are  attended  with  bearing-down  efforts  of  greater  or  less  violence.  Under 
these  expulsive  throes,  the  pulse,  which  was  quicker  than  ordinary  during 
the  first  stage,  becomes  even  more  accelerated ; there  is  increased  heat  of 
skin,  and  soon  a copious  perspiration  breaks  out ; the  mouth  often  becomes 
parched;  the  breath  is  held  in;  and  those  voluntary  muscles,  whose  action 
assists  the  uterus,  are  called  powerfully  into  requisition,  to  aid  the  uterine 
energies.  The  patient  tightly  grasps  whatever  can  give  her  steadiness 
and  support,  places  her  feet  against  some  unyielding  point,  suspends  her 
respiration,  and  strains  with  all  her  might.  Although  the  pains  during  the 
progress  of  the  second  stage  are  stronger  than  in  the  first,  still  the  inter- 
missions are  more  decided,  and  the  intervals  of  ease  more  perfect : they 
are  endured  with  more  composure  and  fortitude ; and  the  woman  usually 
slumbers  between  each  paroxysm,  even  although  she  had  been  unable  to 
sleep  earlier  in  the  process,  in  consequence  of  her  irritability  or  anxiety. 
This  inclination  to  dose  should  be  indulged,  as  it  keeps  the  mind  in  a quiet 
and  calm  state,  refreshes  the  spirits,  and  restores  the  bodily  powers.  At 
other  times,  from  the  moment  the  liquor  amnii  is  evacuated,  the  efforts  of 
the  uterus  become  redoubled,  as  though  some  fresh  excitement  was  applied ; 
and  this  may  probably  arise  from  the  os  uteri  being  irritated  more  by  the 
bony  head  than  by  the  soft  cushion  previously  interposed  between  itself  and 
the  presenting  part. 

After  the  escape  of  the  liquor  amnii,  the  foetal  body  is  more  or  less 
compressed,  in  proportion  to  the  uterine  exertions,  and  the  resistance  offered 
by  the  passages.  It  is  therefore  folded  into  lesser  space,  and  the  chin  is 
directed  more  forcibly  against  the  chest,  so  that  the  neck  is  bent  more  into 
a curve. 

Progression  and  recession  of  the  head. — I have  before  mentioned,  that 
the  membranous  bag,  while  entire,  is  tense,  and  protruded  during  each 


* Essays  on  Midwifery.  No.  2. 


110 


natural  labour,  ( Second  Stage.) 

pain ; that  it  becomes  lax,  and  the  water  recedes,  when  the  pain  goes  off. 
The  same  thing  also  happens  with  regard  to  the  head,  so  far  as  protrusion 
and  retrocession  are  concerned.  After  the  membranes  are  broken,  it  is 
forced  a little  downwards  with  each  contraction ; and  in  the  absence  of 
pain  retreats,  sometimes  to  a considerable  extent.  This  is  particularly 
remarkable  when  it  is  passing  through  the  outlet  of  the  pelvis.  At  that 
period  of  the  labour  it  may  be  almost  entirely  expelled  during  the  urgency 
of  the  pain ; and  when  remission  occurs,  it  will  recede  and  be  again  per- 
fectly buried  within  the  genital  fissure,  so  that  the  labia  close  around  it. 
To  such  an  extent  is  this  recession  sometimes  carried,  that  it  may  give 
those  not  well  acquainted  with  the  process  an  idea  that  the  uterus  has 
ruptured,  and  that  the  child’s  body  has  passed  partly  into  the  abdominal 
cavity.  And  here  again  we  cannot  help  remarking  the  beauty  of  nature’s 
ordinances  : it  is  impossible,  indeed,  to  contemplate  a single  provision,  even 
of  the  minutest  character,  adapted  to  the  exigencies  of  gestation  and 
labour,  without  being  fervidly  and  awfully  impressed  with  the  extent  of 
that  Wisdom,  Power,  and  Beneficence,  which  established  the  laws,  and 
controls  their  operations. 

The  advantage  of  this  retrocession  consists  in  the  removal,  for  a time, 
of  that  distending  pressure  which  obtains  when  the  head  is  propelled 
downwards.  If  there  existed  a constant  urging  forward,  without  the 
least  relief  to  the  parts,  throughout  the  whole  progress  of  the  labour, — 
even  under  the  most  common  natural  case,  in  which  not  more  than  the 
usual  time  was  consumed, — the  soft  structures  must  suffer  very  consider- 
able injury  ; the  vessels  must  be  more  or  less  strangulated ; the  circulation 
would  be  suspended  or  impeded;  inflammation  would  almost  be  a neces- 
sary consequence;  and  gangrene  would  generally  follow.  We  are, 
therefore,  to  hail  this  recession  of  the  head  in  its  progress  through  the 
pelvis  as  a fortunate  occurrence  for  the  woman ; since  it  relieves  her 
from  present  pain  and  future  danger.  It  is  also  to  be  regarded  as  a good 
sign,  inasmuch  as  it  proves  that  the  cavity  of  the  pelvis  is  tolerably 
capacious. 

When  the  head  has  entered  so  low  into  the  pelvis  that  the  forehead  and 
occiput  impinge  respectively  on  the  internal  surface  of  the  tuberosities  of 
each  ischium, — inasmuch  as  the  long  diameter  of  the  head,  while  in  this 
situation,  is  opposed  to  the  short  diameter  of  the  pelvic  outlet,  and  exceeds 
that  diameter  by  half  an  inch,  it  is  impossible  for  it  to  escape  in  that 
direction.  A change  is  consequently  effected : the  face  is  thrown  into  the 
hollow  of  the  sacrum,  and  the  occiput  under  the  arch  of  the  pubes.  This 
alteration  in  position,  however,  does  not  commence  until  the  head  is  fully 
lodged  within  the  pelvic  cavity.  Plate  XXV.  fig.  81,  shows  the  head  oc- 
cupying the  pelvic  cavity,  the  face  being  directed  to  the  right  side. 


StK^atr's  Zz-Zz 


■* 


*5 


7 


Ill 


natural  labour,  [Second  Stage.) 

Compression  of  the  head . — We  also  remark — especially  in  first  labours, 
or  any  case  where  there  is  much  resistance — that  the  head,  from  pressure, 
assumes  somewhat  of  a conical  figure,  the  bones  of  the  cranium  over- 
lapping  each  other,  so  as  to  diminish  the  lateral  diameter.  In  conse- 
quence of  this  decrease  in  volume,  the  scalp  becomes  corrugated, — 
puckered  at  the  vertex  into  three  or  four  folds,  very  evident  to  the  touch, 
and  observable,  cceteris  paribus , in  the  same  degree  as  the  head  is  com- 
pressed. Pressure  to  such  an  extent  is  seldom  injurious.  After  a time, 
however,  when  the  head  has  remained  long  within  the  pelvis,  and 
especially  if  it  be  impacted,  this  corrugated  feeling  of  the  scalp  disap- 
pears ; and  instead  of  it,  a soft  puffy  tumour  is  observed  in  the  same 
situation. 

While  the  head  thus  continues  in  the  pelvis,  both  before  and  after  its 
turn  is  effected, — being  compressed  by  the  pelvic  bones,  and  reciprocally 
exerting  equivalent  pressure  on  the  soft  structures  within  the  cavity, — 
another  most  distressing  symptom  often  arises,  bringing  with  it  great 
increase  of  suffering,  but  not  generally  interfering  with  uterine  action,  or 
retarding  the  progress  of  the  labour ; — I allude  to  cramp,  of  the  most 
violent  character,  affecting  the  calf  and  sole  of  the  foot.  This  is  conse- 
quent on  the  compression  to  which  the  great  sciatic  nerve  is  exposed  at 
this  stage  of  the  process ; and  is  so  painful  that  the  patient  can  scarcely 
restrain  her  screams. 

Exit  of  the  head. — The  vertex,  then,  of  all  the  cranial  surface,  first 
appears  externally,  and  as  it  descends  lower  and  lower,  the  labia  become 
opened  ; the  anus  dilated ; the  perineum  distended,  heated,  and  very  much 
thinned ; so  that  it  feels  almost  like  wet  vellum.  Plate  XXVI.  fig.  83, 
copied  from  Smellie,  the  child’s  head  a , is  seen  separating  the  labia ; the 
extension,  thinning,  and  protrusion  of  the  perineum  b , caused  by  the  head’s 
descent,  and  called  by  some  the  perineal  tumour,  are  also  well  portrayed; 
d marks  the  point  of  the  coxyx;  e the  anus  dilated,  so  that  the  inner 
membrane  of  the  rectum  is  to  some  extent  exposed  to  the  contact  of  the 
hand,  when  applied  for  the  protection  of  the  structures.  This  exposure 
is  not  injurious;  no  harm  arises  from  it;  and  sometimes  it  is  even  greater 
than  is  represented  here.  In  this  way,  retreating  when  the  pain  goes  off, 
and  advancing  when  it  returns,  the  face  sweeps  along  the  sacrum,  coxyx, 
and  perineum;  the  chin  slowly  recedes  from  the  chest;  the  occiput  turns 
up  under  the  arch  of  the  pubes ; the  perineum  slips  back  over  the  partially 
extruded  face ; and  the  head  is  by  degrees  expelled.  On  its  entire  expul- 
sion the  face  is  directed  towards  one  or  other  thigh.  Plate  XXVI.  fig.  84. 

During  the  passage  of  the  head  externally,  the  pains  are  even  more 
forcing  than  have  yet  been  experienced : the  woman  bears  down  more 
strongly,  makes  a greater  effort,  and  calls  forth  the  utmost  power  of  the 


112 


natural  labour,  ( Second  Stage.) 

abdominal  muscles  and  diaphragm,  to  aid  the  uterine  contractions.  It 
appears  as  if  all  the  vital  energies  were  directed  towards  the  accomplish- 
ment of  the  object  nature  has  in  view : most  of  the  muscles  of  the  body 
participate  in  the  general  struggle ; a violent  trembling,  which  it  is  impos- 
sible to  control,  frequently  pervades  the  whole  frame ; and  at  the  moment 
the  head  emerges,  a piercing  shriek  will  mostly  escape  the  patient,  as 
though  involuntarily.  When  the  head  is  on  the  point  of  passing,  the 
contents  of  the  rectum  are  usually  squeezed  out ; and  on  its  entire  protru- 
sion, the  perineum,  from  its  own  elasticity,  recovers  its  former  size  and 
appearance ; it  is  collected  round  the  neck  of  the  child, — the  woman  is 
completely  relieved  from  the  distending  force,  and  consequently  from  the 
agony  she  endured.  She  will  now  generally  express  some  strong  senti- 
ment of  gratitude  and  joy ; or  perhaps  her  feelings  will  only  find  utterance 
in  tears. 

Under  all  states  of  the  system,  the  sudden  removal  of  intense  pain 
brings  with  it  a sensation  of  positive  pleasure ; and  in  no  case  is  the 
instantaneous  transition  from  extreme  misery  to  actual  joy  more  con- 
spicuous than  immediately  on  the  delivery  of  the  head;  and  this  especially 
if  it  be  a primary  labour ; to  which,  indeed,  the  preceding  remarks  are 
more  particularly  applicable.  A longer  interval  of  ease  will  probably 
follow  the  expulsion  of  the  cranium  than  had  occurred  since  the  perineum 
first  began  to  be  extended.  In  a very  few  minutes,  however,  action  is 
is  again  established,  for  the  purpose  of  completing  the  delivery. 

Exit  of  the  body  of  the  child. — After  the  head  has  effected  its  turn, 
with  the  face  into  the  hollow  of  the  sacrum,  and  is  passing  through  the 
outlet  of  the  pelvis,  with  its  long  diameter  in  the  same  direction  as  the 
long  diameter  of  the  inferior  aperture, — namely,  from  the  fore  to  the  back 
part, — the  shoulders  are  at  the  same  moment  entering  the  cavity,  and 
passing  through  the  brim,  with  their  long  diameter  in  the  same  direction 
as  one  of  the  long  diameters  of  the  superior  aperture,  which  is  diagonally 
from  side  to  side ; so  that  the  child  is  here  adapted,  both  as  it  regards  its 
head  and  its  shoulders,  to  the  pelvis,  in  such  a way  as  to  make  its  transit 
the  most  easily.  Plate  XXV.  fig.  82,  represents  the  face  traversing  the 
sacral  cavity,  after  the  head  has  made  its  turn.  The  shoulders  are  seen 
passing  through  the  brim,  with  the  left  directed  towards  the  right  groin, 
and  the  right  opposite  to  the  left  sacro-iliac  symphysis;  the  original  pre- 
sentation of  the  head  having  been  the  vertex  with  the  face  to  the  right 
ilium.  In  most  of  the  plates  which  describe  this  position  of  the  foetal  head, 
the  body  is  also  turned  quite  round,  with  the  abdomen  looking  directly  to- 
wards the  mother’s  spine.  From  repeated  observation,  I am  persuaded 
that  this  is  not  correct ; that  the  body  still  in  utero  is  not  turned  in  the 
same  proportion  as  is  the  head ; and  that  the  cervical,  dorsal,  and  lum- 


113 


natural  labour,  ( Second  Stage. ) 

bar  vertebra)  are  somewhat  twisted ; so  that  the  breach  and  lower  part  of 
the  trunk  retain  their  original  situation  in  regard  to  the  mother’s  body,  al- 
though the  head  has  been  so  materially  altered  in  respect  to  that  which  it 
occupies.  This  is  proved  by  the  child’s  face  being  directed  to  one  of  the 
woman’s  thighs  immediately  on  its  expulsion.  After  the  head  is  born, 
however,  when  the  shoulders  have  come  down  to  press  upon  the  outlet  of 
the  pelvis,  their  long  diameter  is  opposed  to  the  short  diameter  of  the  out- 
let, and  they  seldom  can  make  their  exit  in  this  situation,  unless  the 
child  be  small  or  ill-formed : but  most  usually  they  also  effect  a turn, 
similar  to  the  turn  already  described  by  the  head ; one  of  them  being 
directed  into  the  cavity  of  the  sacrum,  and  the  other  insinuating  itself 
under  the  arch  of  the  pubes.  Through  the  inferior  aperture  of  the  pelvis, 
then,  the  child  is  expelled  sideways,  one  shoulder  and  arm  distending 
the  perineum,  and  the  other  offering  itself  anteriorly.  Plate  XXVI. 
fig.  84.  One  pain  may  be  sufficient  to  effect  this  turn  and  expel  the 
shoulders ; or  two  or  three  may  be  required. 

When  the  foetal  body  is  so  far  protruded  that  the  parts  are  again 
distended  by  the  shoulders,  the  patient  experiences  a return  of  pain ; not 
such  violent  agony,  certainly,  as  when  the  head  was  being  expelled,  but 
the  same  feeling  of  forcible  distention, — the  same  sensation  as  if  the  parts 
were  being  rent.  A short  time  only  elapses  before  the  uterus  resumes  its 
action,  to  expel  the  breech ; the  child  in  the  interval  remaining  half  born, 
the  perineum  somewhat  on  the  stretch.  As  the  breech  takes  up  less  room 
than  either  the  head  or  shoulders,  it  is  usually  extruded  with  slight  exer- 
tion ; the  legs  and  feet  either  pass  directly,  or  remain  a minute  or  two  in 
the  vagina,  and  are  ultimately  expelled  by  the  vaginal  fibres : the  birth  of 
the  child  is  then  perfected,  and  the  second  stage  of  the  labour  brought  to 
a close* 

. The  time  occupied  by  the  passage  of  the  child,  after  the  rupture  of  the 
membranes,  is  as  uncertain  as  the  period  required  for  the  dilatation  of  the 
os  uteri  and  the  accomplishment  of  the  first  stage.  Sometimes  the  same 
pain  under  which  the  membranes  burst,  expels  the  head,  and  perhaps  the 
body  also ; at  others,  very  many  hours  of  "wearying  suffering  are  sustained 
before  the  head  emerges ; and  the  same  uncertainty  with  regard  to  time 
applies — but  in  a very  limited  degree — to  the  passage  of  the  shoulders 
after  the  head  is  born ; sometimes  scarce  a moment  intervenes,  sometimes 
a considerable  space;  usually,  however,  the  child  is  entirely  expelled 
within  five  minutes  after  the  head  has  passed. 

The  symptoms  of  a speedy  termination  to  the  labour  are,  that  from  the 
beginning  we  should  find  the  os  uteri  lax,  soft,  thick,  moist,  cool,  and  not 
tender ; that  we  should  find  the  vagina  also  soft,  moist,  relaxed,  and  cool, 
15 


114 


natural  labour,  ( Third  Stage.) 

and  the  perineum  easily  distensible ; the  pelvis  well  formed;  the  head 
directed  with  the  face  laterally,  or  looking  diagonally  backwards,  with 
the  vertex  downwards.  With  such  indications,  if  the  woman  be  in  good 
health,  and  the  pains  pretty  active,  we  may  expect  a speedy  termination 
to  the  case. 

The  symptoms  foreboding  a tedious  labour  are  exactly  the  contrary  to 
those  I have  just  mentioned: — that  we  should  find  the  os  uteri  thin,  hard, 
unyielding,  dry,  and  tender,  and  feeling  round  the  presenting  part  of  the 
head  as  if  a cord  were  tightly  encircling  it ; that  the  vagina  and  perineum 
should  be  dry,  hot,  narrow,  and  constricted ; that  the  head  should  be 
wrongly  placed ; the  pelvis  small ; or  the  uterine  action  feeble : any  of 
these  features  displaying  themselves  will  indicate  the  probability  of  a pro- 
tracted struggle. 

Usually,  when  the  os  uteri  has  been  pretematurally  rigid,  the  soft  struc- 
tures towards  the  outlet  of  the  pelvis  are  also  indisposed  to  yield,  and  the 
labour  is  therefore  tedious  from  the  commencement  to  the  close : but  this 
is  by  no  means  always  so;  for  sometimes  these  parts  will  give  way  very 
easily  after  the  os  uteri  has  opened  with  great  difficulty ; and  in  other  cases 
they  will  be  very  rigid,  when  the  os  uteri  has  dilated  tolerably  easily.  It 
may  be  looked  upon  as  a general  rule,  that  the  vagina  and  perineum  are 
least  disposed  to  dilate  in  first  labours ; and  this  observation  is  more  uni- 
versally applicable  to  them  than  to  the  mouth  of  the  womb.  We  very 
seldom,  indeed,  find  either  of  these  organs  more  rigid  in  subsequent  labours 
than  in  the  first,  unless  that  rigidity  is  the  consequence  of  a cicatrix  pro- 
duced by  sloughing.  It  is  possible  that  after  a difficult  labour  inflamma- 
tion of  the  vagina  may  occur,  which  may  terminate  in  slough ; the  slough 
will  separate,  the  ulcer  will  heal,  a puckering  will  take  place,  and  a cica- 
trix will  be  left ; by  which  processes  the  capacity  of  the  canal  is  much 
diminished,  and  its  dilatability  impaired : but  this  is  an  accidental  occur- 
rence, and  must  be  reserved  for  future  consideration. 

Third  Stage. — The  second  stage  being  terminated  on  the  birth  of  the 
child,  the  third  consists  in  a continuation  of  the  same  efforts  for  the  expul- 
sion of  the  placenta. 

Varieties  in  the  time  occupied  in  the  expulsion  of  the  placenta. — This 
stage  also  varies  much  in  respect  to  time : if  the  uterus  be  vigorous  and  ac- 
tive, the  placenta  is  generally  expelled  quickly ; but  if  uterine  action  has  been 
feeble  during  the  former  parts  of  the  process  (particularly  if  the  labour 
has  been  lingering,  or  the  child  has  been  extracted  by  mechanical  means,) 
a comparatively  long  period  usually  elapses  before  it  passes.  In  some  in- 
stances, indeed,  the  uterus  does  not  act  to  expel  it  at  all,  and  the  introduc- 


115 


natural  labour,  ( Third  Stage.) 

tion  of  the  hand  is  required  for  its  removal.  1 have  sometimes  known  the 
placenta  thrown  out  of  the  vagina  by  the  same  pain  that  expelled  the 
child : more  frequently,  ten,  fifteen,  or  twenty  minutes  elapse,  before  it 
escapes  wholly  from  the  uterus  into  the  vagina,  and  even  then  it  may  lie 
in  that  cavity  for  hours  before  it  clears  the  os  externum.  Those  contrac- 
tions, by  which  the  expulsion  of  the  placenta  from  the  uterus  is  effected, 
are  also  attended  with  suffering ; not,  indeed,  nearly  approaching  the  vio- 
lence of  the  pains  under  which  the  fcetusvwas  born,  but  more  like  the 
uneasy  sensations  experience^during  the  commencement  of  the  first  stage: 
they  are  referred  principally  to  the  loins  and  upper  region  of  the  sacrum, 
and  are  scarcely  complained  of.  It  is  seldom  that  a single  pain  expels  it 
even  out  of  the  uterine  cavity  ; more  frequently  three  or  four  follow  each 
other,  at  tolerably  regular  intervals ; and  it  descends  into  the  vagina  by 
degrees. 

When  it  has  passed  from  the  uterus — if  the  case  be  left  entirely  to  the 
natural  powers — the  muscular  fibres  of  the  vagina  complete  its  extrusion  ; 
but  as  this  canal  has  suffered  severe  and  unusual  distention  during  the  birth 
of  the  child,  we  cannot  expect  that  the  muscular  coat  will  regain  its  pre- 
vious tone  in  an  instant,  so  completely  as  to  embrace  the  mass  firmly  and 
expel  it  immediately.  It  consequently  remains  within  the  vagina,  until 
the  fibres  have  recovered  sufficiently  to  act  upon  it.  This  requires  a very 
different  period  in  different  instances : sometimes  five  or  six  hours  will 
elapse ; most  usually  it  is  protruded  within  the  hour. 

Separation  of  the  placenta  from  its  uterine  attachment. — Previously, 
however,  to  the  placenta  being  expelled  out  of  the  uterine  cavity,  it  must 
be  separated  from  its  uterine  attachment.  This  separation  is  produced 
exactly  by  the  same  action  which  causes  its  extrusion, — uterine  contrac- 
tion. After  the  birth  of  the  infant,  the  general  volume  of  the  uterus  and 
the  capacity  of  its  cavity  being  diminished  in  proportion  to  the  degree  of 
contraction  it  has  undergone,  it  necessarily  follows  that  the  uterine  sur- 
face, before  occupied  by  the  placenta,  is  proportionably  decreased,  and 
shrinks  into  a less  space. 

As  the  placenta  is  a perfectly  passive  body — as  there  is  no  power  inhe- 
rent within  its  own  structure,  by  which  its  maternal  face  can  be  diminished 
in  any  degree  corresponding  with  the  diminution  of  the  internal  surface  of 
the  uterus — the  very  shrinking  of  the  uterine  parietes  occasions  it  to  lose 
its  former  hold ; it  spontaneously  falls  from  its  attachment,  and  would 
remain  loose  in  the  uterine  cavity,  unless  extruded  by  a continuance  of 
uterine  action.  This  simple  contraction,  then,  causing  the  uterine  mem- 
brane to  slip  away  from  the  placental  surface,  both  separates  it  from  its 
connexion  and  expels  it  from  its  cavity.  The  placenta  passes  through  the 


116 


natural  labour,  (Management. ) • 

vagina  inverted,  so  that  its  foetal  face  becomes  external ; the  membranes 
attached  to  it  are  also  turned  inside  outwards,  and  are  flapped  over  its 
maternal  surface.  There  is  always  a loss  of  more  or  less  blood  accom- 
panying the  separation  of  the  placenta ; and  this  blood  appears  externally 
upon  the  linen.  The  quantity  varies  to  a great  extent;  sometimes  it  does 
not  exceed  an  ounce  or  two  ; at  others  it  amounts  to  many  pints,  consti- 
tuting a most ‘violent  haemorrhage. 

Even  after  the  placenta  has  been  expelled  from  the  uterine  and  vaginal 
cavities,  the  process  of  uterine  contraction  ^es  not  cease,  but  continues 
for  the  purpose  of  arresting  the  flow  of  blood  by  the  closure  of  the  vessels; 
for  preventing  the  possibility  of  the  womb  being  inverted ; and  for  silently 
and  gradually  decreasing  the  bulk  of  the  organ  to  its  former  small  unim- 
pregnated state.  Should  the  uterus  not  contract,  in  proportion  to  the 
flaccidity  of  its  parietes,  the  distensibility  of  its  cavity,  and  the  pervious- 
ness of  its  vessels,  would  be  the  danger  of  haemorrhage.  It  does  not  per- 
haps necessarily  follow  that  dangerous  flooding  must  occur,  even  although 
the  contraction  were  imperfect ; because  it  is  possible  that  coagula  might 
form  at  the  open  apertures  of  the  uterine  vessels  which  were  previously 
closed  by  the  apposition  of  the  placenta;  and  if  the  heart’s  action  were 
not  powerful  enough  to  dislodge  those  coagula,  the  loss  of  much  blood 
might  be  by  them  prevented.  But  this  kind  of  plug  is  a most  inefficient 
security  against  all  varieties  of  uterine  haemorrhage ; and  no  woman  can 
be  considered  safe  from  flooding  until  the  uterus  is  firmly,  entirely,  and 
permanently  contracted. 

Every  one  who  has  seen  much  of  obstetric  practice  must  have  been 
struck  with  the  fortitude  and  resignation  with  which  women  bear  the  ago- 
nizing throes  of  parturition,  and  the  rapidity  with  which  the  system 
recovers  from  the  lengthened  suffering,  and  regains  its  average  balance. 
This  must  be  regarded  as  one  of  Nature’s  greatest  mercies ; but  there  is 
this  grand  difference  between  the  pain  of  labour  and  all  other  pains — the 
one  is  unnatural,  and  dependent  on  morbid  actions,  influencing  for  the 
time  the  condition  of  the  organ  affected ; the  other  is  natural,  and  insepa- 
rably connected  with  the  performance  of  a healthy  function. 

Duties  of  the  Medical  Attendant  under  natural  labour. — From  the 
knowledge  which  the  foregoing  pages  will  afford  of  the  beneficence  dis- 
played by  nature  throughout  the  processes  of  utero-gestation  and  labour ; 
and  of  the  admirable  contrivances  adopted  by  her  to  overcome  difficulties 
and  avert  dangers,  it  will  be  evident  that  in  a very  large  proportion  of 
cases  the  duties  of  the  obstetrician  must  be  few  and  simple.  Generally, 
indeed,  no  active  assistance  is  necessary,  until  after  the  birth  of  the  child ; 


117 


natural  labour,  ( Management .) 

all  that  is  required  of  the  attendant  being,  that  he  should  remain  an  obser- 
vant, though  unofficious,  spectator  of  the  process ; — ready  to  exert  himself, 
with  promptitude  and  energy,  on  the  first  accession  of  any  alarming  symp- 
tom ; but  equally,  or  more,  ready  to  allow  the  changes  necessary  for  the 
completion  of  nature’s  object  to  proceed,  uninterrupted  by  any  meddle- 
some interference : for  no  maxim  in  obstetric  science  is  of  more  universal 
application,  than  that  unnecessary  “ assistance,” — rendered  with  the  view 
of  expediting  the  termination  of  the  case,  or  shortening  the  sufferings  of 
the  patient — is  not  only  useless,  but  in  the  highest  degree  injurious,  and 
well  calculated  to  defeat  its  own  end. 

Let  it  not  be  supposed  this  declaration  includes  the  admission  that  a 'par- 
tial acquaintance  with  the  obstetric  branch  of  medicine  is  sufficient  for 
the  safe  practice  of  the  profession ; for  although,  in  thirty-nine  cases  out 
of  forty,  little  is  required  to  be  done  beyond  protecting  the  extended  struc- 
tures from  injury,  separating  the  child,  and  extracting  the  placenta  from 
the  vagina — after  its  total  exclusion  from  the  uterine  cavity — still,  in  the 
fortieth,  danger  may  occur,  only  to  be  arrested  by  the  promptest,  the  most 
decisive,  and  most  judiciously  directed  help. 

Much  knowledge  is  necessary  to  discriminate  the  kind  of  cases  in  which 
assistance  is  proper,  and  determine  the  time  at  which  that  assistance  ought 
to  be  employed,  as  well  as  the  mode  of  its  application.  It  is  this  which 
distinguishes  the  scientific  from  the  ignorant  obstetrician  ; — it  is  this  im- 
portant knowledge  on  which  the  life,  the  future  health  and  comfort  of 
many  a parturient  woman  must  depend ; — which,  nevertheless,  has  been 
held  in  such  low  estimation  by  some  members  of  the  profession,  as  to  be 
thought  unworthy  of  cultivation  by  the  scientific  and  literary  mind ; — unfit 
to  be  possessed  by  men  of  respectable  station  in  society ; and  the  adapta- 
tion of  which  knowledge  to  practice  has  been  characterized  in  an  official 
document  under  the  seal  of  the  highest  of  our  medical  corporate  associa- 
tions, as  “ an  art  foreign  to  the  habits  of  gentlemen  of  enlarged  .academi- 
cal education.”* 

No  one  can  read  this  sentiment  without  feeling  that  it  is  both  inconsi- 
derate and  unjust.  To  omit,  indeed,  any  particular  mention  of  the  science 
and  judgment  requisite  to  treat  such  perilous  accidents  as- haemorrhage,  in 
all  its  varieties,  and  convulsions,  a most  important  question, — involving 
no  less  than  the  destruction  of  foetal  life, — is  often  painfully  forced  upon 
the  attention  of  the  obstetric  practitioner.  He  is  by  no  means  very  unfre- 
quently  called  upon  to  decide  whether  the  delivery  can  safely  be  trusted 
to  the  natural  powers,  or  requires  to  be  terminated  by  artificial  aid ; and 

* Letter  from  the  Royal  College  of  Physicians  to  the  Secretary  of  State  for  the  Home  De- 
partment, dated  May  2d,  1827,  in  reply  to  a Ynemorial  from  the  Obstetric  Society. 


118  natural  labour,  ( Management .) 

whether  means  may  be  used  compatible  with  the  child’s  safety,  or  the 
horrible  alternative  must  be  had  recourse  to,  of  sacrificing  the  infant  to 
preserve  the  mother. — Is  it  of  no  importance  that  this  should  be  deter- 
mined by  an  educated,  intelligent,  and  practical  man  ? — Is  it  right  that 
questions  of  such  vital  interest  should  be  left  to  the  decision  of  one  but 
partially  qualified  to  answer  it  T — And  can  we  suppose  that  any  person 
can  form  a proper  estimate  of  the  powers  with  which  nature  is  endowed 
to  surmount  the  impediments,  and  overcome  the  dangers,  that  occasionally 
embarrass  parturition,  unless  he  have  the  opportunity  continually  before 
him  of  watching  her  operations  in  the  more  ordinary  cases  ? — For  these, 
if  for  no  other  reasons,  the  interests  of  the  public  must  be  best  protected 
when  the  obstetrical  branch  of  medicine  and  surgery  is  undertaken, — in 
common  wdth  the  other  duties  of  those  sciences, — by  persons  who  have 
qualified  themselves,  by  their  medical  studies,  for  the  conduct  of  the  most 
dangerous  casualties,  and  who  are  entitled,  by  their  rank  in  society,  and 
their  preliminary  education,  to  the  consideration  of  gentlemen. 

It  can  scarcely  be  necessary  that  I should  insist  on  the  obligation  we 
lie  under  to  obey  every  summons  to  an  obstetric  patient  as  speedily  as 
possible : for  even  although  a former  one  may  have  been  lingering,  it  by 
no  means  follows  that  the  subsequent  labours  should  be  of  the  same  nature  ; 
and  a practitioner  must  subject  himself  to  much  annoyance  and  blame,  if, 
through  remissness  or  negligence  on  his  part,  he  should  find  the  case  termi- 
nated on  his  arrival.  It  is  always  right — however  little  is  required  to  be 
done — that  the  medical  attendant  should  be  present  during  the  chief  period 
of  the  process,  that  he  maybe  at  hand  to  employ  such  means  as  any  emer- 
gency may  render  requisite. 

A lancet  and  a female  catheter  are  the  only  instruments  with  which  the 
obstetrical  practitioner  need  furnish  his  pocket  case",  sufficient  time  will 
generally  be  afforded  him  for  procuring  any  others  he  may  want,  even 
in  the  most  urgent  cases.  He  will  find  it  convenient,  however,  espe- 
cially in  country  practice,  to  carry  with  him  two  or  three  drachms  of 
laudanum. 

It  is  not  often  that  we  are  called  upon  to  choose  the  apartment  in  which 
the  woman  should  pass  the  puerperal  month,  as  she  is  usually  delivered  in 
her  own  bed-room;  but  if  that  advantage  be  afforded  us,  we  should 
make  choice  of  one  that  is  spacious  and  airy,  with  a dressing-closet  or 
ante-room  attached  to  it,  and  at  a convenient  distance  from  the  domestic 
offices. 

Nor,  perhaps,  are  we  generally  expected  to  regulate  the  number  of  indi- 
viduals to  be  present ; though  we  may  be  called  upon  not  unfrequently  to 
exercise  our  authority  in  this  respect.  Bearing  in  mind  that  the  room 


119 


natural  labour,  ( Management .) 

should  be  kept  as  noiseless  as  possible,  there  are  yet  some  attendants 
whose  services  we  cannot  dispense  with.  The  only  persons  whom  1 
would  willingly  admit  are  the  nurse  and  some  female  married  friend, — the 
mother,  or  other  near  relation,  or  an  intimate  acquaintance, — to  act  as 
confidante  to  the  sufferer,  into  whose  sympathizing  ear  she  may  whisper 
all  her  grievances  and  distresses,  and  from  whom  she  may  receive  those 
numberless  comforts  and  sustaining  consolations  of  which  she  stands  so 
eminently  in  need.  Unmarried  females  are  neither  the  most  fit  companions 
for  the  patient,  nor  the  most  useful  assistants  to  the  practitioner.  In  addi- 
tion, it  is  proper  that  a servant  should  be  in  attendance  in  the  ante-room, 
or  close  at  hand,  that  she  maybe  ready  to  bring  whatever  may  be  wanted 
from  a distant  part  of  the  house  without  delay ; and  she  should  have  no 
duty  imposed  on  her  for  the  time,  except  an  obedience  to  the  orders  that 
may  issue  from  her  mistress’s  chamber. 

On  arriving  at  the  patient’s  residence  it  is  better  not  abruptly  to  obtrude 
oneself  into  her  presence,  unless  there  be  some  immediate  necessity  for 
our  attendance.  Information  should  be  sought  from  the  nurse  on  such 
points  as  will  enable  us  to  judge  whether  labour  has  actually  commenced. 
On  being  ushered  into  her  chamber,  we  may  engage  her  in  some  general 
conversation,  which  will  give  us  an  opportunity  of  observing  the  frequency, 
duration,  strength,  and  character  of  the  pains ; and  our  conduct  must  be 
framed  accordingly.  Should  they  be  of  trifling  importance,  we  may  con- 
tent ourselves  with  giving  some  ordinary  directions,  and  retire  from  the 
apartment.  But  if  they  are  returning  with  frequency  and  activity,  we 
must  not  allow  much  time  to  elapse  before  we  require  to  make  an  exami- 
nation per  vaginam. 

An  objection  may  be  raised  by  the  patient  to  the  necessary  examination 
being  then  instituted,  under  the  idea  that  no  assistance  can  be  rendered 
her  so  early  in  the  labour.  As  I would  regard  the  feelings  of  a parturient 
woman  in  a degree  only  secondary  to  her  safety,  I would  by  no  means 
insist  on  putting  her  to  this  inconvenience,  unless  I thought  it  quite  indis- 
pensable. But,  as  much  valuable  information  may  be  gained  by  this  first 
examination,  and  as  it  is  highly  desirable  to  obtain  that  information  during 
the  progress  of  the  first  stage,  it  is  right  firmly  but  gently  to  urge  its  pro- 
priety. It  is  seldom,  indeed,  that  she  will  not  accede  to  the  recommenda- 
tion of  her  medical  attendant,  provided  he  possesses  her  confidence,  and 
conveys  his  request  with  becoming  delicacy. 

Mach  knowledge  must  he  acquired  during  the  first  vaginal  examina- 
tion: it  is,  first,  whether  the  woman  be  pregnant;  secondly,  if  she  be  in 
labour;  thirdly,  whether  the  membranes  have  ruptured,  or  are  still  entire; 
fourthly,  how  the  child  is  presenting ; fifthly,  how  far  the  labour  is  advanced ; 


120 


natural  labour,  ( Management .) 

and  sixthly,  the  state  of  the  os  uteri,  vagina,  and  perineum,  in  regard  to 
their  distensibility. 

It  may  be  thought  superfluous  to  recommend  that  one  of  the  points  of 
inquiry  should  be  whether  pregnancy  really  exists,  under  the  supposition 
that  no  woman  could  believe  herself  in  labour  unless  she  had  approached 
near  the  termination  of  utero-gestation.  But  instances  are  daily  occur- 
ring which  prove  the  fallacy  of  this  mode  of  reasoning ; and  on  many 
occasions  professional  men  have  been  in  attendance  for  days  and  weeks, 
relying  on  their  patient’s  assurances,  perhaps  often  advanced,  that  she  was 
with  child,  when  it  has  turned  out  she  was  mistaken.  They  have  thus 
most  undeservedly  exposed  themselves. to  some  censure,  or,  what  is  per- 
haps more  mischievous  than  direct  censure,  to  quizzical  innuendos  and 
sarcastic  ridicule. 

Many  unhealthy  actions  will  cause  the  abdomen  to  swell, — especially 
about  the  period  of  the  cessation  of  the  menstrual  discharge, — and  to  simu- 
late the  external  appearance  of  gestation;  and  even  in  the  absence  of  preg- 
nancy, spasms  of  different  muscles  may  sometimes  tolerably  closely  imi- 
tate, as  to  sensation,  situation,  and  severity,  the  commencing  pains  of 
labour.  While  this  gradual  enlargement  is  going  on,  the  woman  will  find 
no  difficulty  in  persuading  herself,  or  in  being  persuaded  by  others,  that 
she  is  pregnant ; and  when  the  spasmodic  pains  set  in,  she  will  as  readily 
conclude  that  labour  has  begun.  Under  such  circumstances,  the  medi- 
cal attendant  has  probably  no  opportunity  of  forming  a correct  judg- 
ment, except  from  his  personal  observations  at  the  time  he  is  hastily  sum- 
moned. 

Provided  the  uterus  be  unimpregnated  the  deception  may  generally  be 
detected,  simply  by  placing  the  hand  on  the  abdomen ; but  if  that  proceed- 
ing does  not  afford  the  required  information,  an  examination  per  vaginam 
can  scarcely  fail  to  prove  satisfactory.  On  placing  the  hand  on  the  abdo- 
men externally,  it  will  be  found  distended — perhaps  from  flatus  pent  up  in 
the  intestines — perhaps  from  fluid  effused  into  the  peritoneal  cavity — or 
from  the  presence  of  some  more  solid  tumour.  We  may  distinguish  that 
the  swelling  is  softer  or  harder,  larger  or  smaller,  more  diffused  or  more 
circumscribed,  than  is  the  bulk  of  the  gravid  uterus ; that  it  is  not  of  the 
same  shape,  is  very  likely  irregular  on  its  surface,  does  not  occupy  the 
same  position,  and  above  all,  that  it  does  not  possess  that  peculiar  springy 
elasticity  which  so  strongly  characterizes  the  impregnated  womb  at  the 
end  of  the  natural  term  of  gestation.  If  there  still  remains  any  doubt,  it  is 
right  to  make  a vaginal  examination.  Under  this  condition  of  spurious 
pregnancy  the  os  uteri  will  be  found  not  only  close,  but  undeveloped ; the 
cervix  not  expanded ; and  the  uterus  itself,  on  poising  it  at  the  extremity 


121 


n a t u r a i-  labour,  ( Management .) 

of  the  finger,  will  be  felt  small,  light,  and  moveable; — provided,  indeed,  it 
be  not  diseased.  If,  on  the  contrary,  the  patient  be  pregnant,  and  near  the 
end  of  the  term,  we  shall  find  the  os  and  cervix  uteri  fully  developed  and 
expanded,  and  perhaps  the  os  uteri  somewhat  open ; so  that  we  may  be 
able  to  detect  the  presence  of  a foetus  through  the  dilated  mouth  or  thinned 
neck. 

But  the  patient  may  be  pregnant  and  not  in  labour, — the  pains  may  be 
spurious  and  not  true.  If  what  has  been  already  advanced  in  regard  to 
false  pains  be  carefully  studied,  I trust  there  will  be  no  great  difficulty  in 
forming  a diagnosis.  We  will  presume,  as  indeed  we  shall  find  most 
usually  the  case,  that  the  patient,  on  our  arrival,  is  in  the  first  stage  of 
labour,  experiencing  the  dilating  or  grinding  pains. 

Position  of  the  patient . — The  most  convenient  as  well  as  easy  posture 
which  the  patient  can  take,  and  that  which  seems  best  adapted  for 
facilitating  the  descent  of  the  head  through  the  pelvic  brim,  is  the  one 
usually  chosen  in  this  country — the  left  side,  with  the  shoulders  inclined 
forwards,  so  that  the  spine  may  be  somewhat  curved,  the  thighs  flexed 
upon  the  pelvis,  and  the  legs  bent  upon  the  thighs.  In  this  position,  as  has 
been  before  shown,  the  axis  of  the  pelvic  entrance  is  brought,  as  nearly  as 
can  be  accomplished,  into  a line  with  the  axis  of  the  trunk ; and  the  mus- 
cles passing  over  the  pelvic  brim,  particularly  the  psose,  are  more  perfectly 
relaxed  than  in  any  other.* 

It  is  better  that  she  should  be  undressed,  excepting  her  night-clothes  and 
a dressing-gown ; and  that  she  should  lie  on  a mattrass  rather  than  a softer 
bed.  She  should  be  also  covered  by  a light  counterpane,  or  blanket,  and  a 
sheet. 

In  this  position  the  vaginal  examination  is  to  be  conducted  in  the  fol- 
lowing manner : — The  attendant  sitting  rather  behind  her,  and  having 
anointed  the  first  two  fingers  of  his  right  hand  with  some  unctuous  sub- 
stance, mostly  in  readiness,  is  to  place  them  on  the  labia  externa ; then 
gently  separating  these  organs,  he  must  introduce  the  first  finger  into  the 
vagina  in  the  direction  of  its  entrance,  which  is  backwards  and  upwards : 
or  he  may  take  the  perineum  as  his  guide,  and  insinuate  his  finger  within 
the  genital  fissure,  posteriorly,  close  to  the  fourchette.f  Having  introduced 


* In  many  parts  of  the  continent  the  women  are  delivered  in  the  half-sitting,  half- recum- 
bent posture.  In  France  they  lie  on  the  back,  with  the  thighs  extended  and  the  knees  drawn 
up.  In  other  countries  they  sit  upon  the  knee  of  an  assistant.  The  peasantry  of  Ireland 
place  themselves  on  their  hands  and  knees;  and  Mr.  Michell  (on  the  Ergot)  states,  that  in 
Cornwall  it  is  difficult  to  persuade  a woman  in  labour  to  take  any  other  posture  than  either 
standing  or  on  her  knees. 

t The  object  of  covering  the  finger  with  some  oily  substance  before  making  an  examina- 
tion, is  two-fold : partly  beeausc  the  lubrication  assists  its  introduction,  but  partly  also  to  diini- 
16 


122 


natural  labour,  ( Management .) 

it  as  high  as  he  conveniently  can,  he  must  pronate  his  wrist  so  that  the 
junction  of  the  first  and  second  finger  shall  fit  in  under  the  symphysis  pubis. 
Plate  XXVII.  fig.  85.  In  this  way  he  will  be  able  usually  to  reach  the  os 
uteri  without  difficulty.  Should  that  organ,  however,  be  situated  so  high 
that  he  cannot  perfectly  command  it, — rather  than  remain  in  ignorance  of 
its  condition,  and  of  the  presentation  of  the  child, — he  may  introduce 
the  first  two  fingers  of  his  left  hand,  fig.  86 ; and  as  these  may  be  passed 
higher  within  the  pelvis,  they  will  give  a greater  facility  for  inquiry.* 

These  examinations  are  commonly  made  during  the  urgency  of  pain ; 
and  this  has  given  rise  to  the  phrase  of  “ trying  a pain.”  It  is,  how- 
ever, desirable,  on  many  accounts,  that  we  should  not  introduce  our 
finger  up  to  the  os  uteri  at  the  time  when  the  uterus  is  acting  strongly ; 
because  then  the  membranes  are  protruded  into  the  vagina  ; and  if  we  press 
against  them  at  that  moment,  we  may  probably  rupture  the  cyst,  and  lose 
its  influence  in  the  after  progress  of  the  labour.  Besides,  it  is  impossible 
under  such  protrusion  to  ascertain  the  presenting  part  of  the  foetus  with 
precision,  because  of  the  quantity  of  water,  which  is  then  interposed 
between  our  finger  and  its  person.  Nevertheless,  as  it  is  expected  that  we 
should  examine  while  the  uterus  is  in  action, — and,  indeed,  as  in  many 
cases  the  patient  would  not  allow  us  to  pass  our  finger  at  all,  were  it  not 
for  the  belief  that  we  can  assist  her,  and  that  only  in  the  time  of  pain, — it 
is  necessary  that  we  should  request  her  to  inform  us  when  there  is  a return, 
and  take  that  opportunity  of  introducing  our  finger  within  the  external 
parts.  Having  gained  this  advantage,  we  must  allow  it  to  remain  inac- 
tive in  the  vagina,  while  the  pain  continues ; and  upon  its  cessation,  which 
we  have  seldom  any  difficulty  in  ascertaining,  we  may  direct  it  up  to  the 
os  uteri. 

The  condition  of  that  organ  with  respect  to  its  actual  dilatation,  and  its 
dilatability,  whether  the  membranous  cyst  is  ruptured  or  is  still  entire,  the 
presentation  of  the  child,  and  the  degree  of  relaxation  which  the  vagina 
and  the  perineum  have  already  taken  upon  themselves,  will  all  become 
matters  of  observation  during  this  primary  examination. 

nish  the  chance  of  inoc.ulation  with  morbid  matter,  should  the  patient  be  labouring  under  any 
venereal  affection.  Three  of  my  intimate  medical  friends  have  suffered  most  severely  from 
secondary  symptoms  of  syphilis  communicated  in  this  manner  ; and  five  different  mid-wives 
of  the  Royal  Maternity  Charity  have  been  the  subjects  of  the  same  disease,  contracted  through 
an  abrasion  of  the  cuticle,  while  in  attendance  on  women  in  labour.  These  are  grievous  acci- 
dents, and  no  means  should  be  left  unused,  by  which  such  a serious  consequence  may  be 
avoided.  If,  unfortunately,  a suspicious  looking  sore  should  make  its  appearance  on  the 
finger,  all  obstetric  duties  must  be  abandoned  until  after  it  is  healed;  for  another  woman  may 
be  infected  from  the  contact  of  an  open  chancre  on  the  hand  of  the  medical  practitioner. 

* The  two  figures  in  Plate  XXVII.  show  the  os  uteri  in  the  process  of  dilatation,  and  the 
mode  of  examination;  fig.  85  displays  it  but  slightly  opened;  fig.  86,  when  it  has  acquired  a 
greater  diameter. 


PL.XXVH 


Fig  S& 


Fig.85. 


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m 


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■ * 


LIBRARY' 

Hi'  THE 

UNIVERSITY  OF  ILLINOIS 


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4 • » 


* 


123 


natural  labour,  {Ma?iagement.) 

In  regard  to  the  first  of  these  points,  it  is  not  always  easy  for  a novice 
to  distinguish  the  mouth  of  the  womb  at  the  commencement  of  labour.  I 
have  known  many  students  attend  a number  of  cases  before  they  had  been 
able  to  detect  the  os  uteri  by  the  feel,  or  satisfy  themselves  where  it  was 
situated.  I have  before  stated  that  it  will  generally  be  met  with  about 
two  inches  or  two  inches  and  a half  from  the  vulva,  looking  back  towards 
the  sacrum  or  coxyx. 

Being  satisfied  that  we  feel  the  os  uteri,  we  must  next  ascertain  whether 
the  membranous  cyst  has  broken  or  not.  It  is  not  always  easy  to  deter- 
mine this  point  either  in  the  interval  of  uterine  contraction ; because  the 
membranes  being  then  flaccid,  retreat,  together  with  the  contained  fluid, 
within  the  uterus ; and  there  remains  merely  a thin  skin,  as  it  were,  between 
the  finger  and  the  presenting  part  of  the  child ; so  slight,  indeed  as  scarcely 
to  be  perceptible  to  the  touch.  But  as  soon  as  pain  returns,  the  soft  wedge, 
if  unbroken,  is  again  felt  protruding  through  the  os  uteri,  and  there  is  then 
no  difficulty  in  detecting  it.  If,  therefore,  we  have  not  been  able  to  learn, 
in  our  first  examination,  whether  or  not  the  liquor  amnii  is  evacuated — 
inasmuch  as  we  have  carried  our  finger  up  to  the  os  uteri  in  the  absence 
of  pain, — we  may  take  the  opportunity  of  examining  again  when  the 
next  contraction  comes  on ; and  on  passing  the  index  finger  up  to  the 
pelvic  brim  while  the  pain  is  urgent, — most  carefully,  lest  we  should  rup- 
ture the  sac  prematurely, — if  we  distinctly  feel  them  protruding  down- 
wards into  the  vagina,  we  know  that  the  membranes  are  still  entire. 

Again,  it  is  of  first  importance  that  we  should  ascertain  what  part  of 
the  child  presents,  even  before  the  membranes  rupture.  The  necessity, 
indeed,  of  determining  the  presentation  previously  to  the  discharge  of  the 
waters,  is  denied  by  some  obstetricians  of  great  authority.* 

With  such  a dangerous  sentiment  I can  by  no  means  Coincide  ; consi- 
dering it  imperative  on  every  practitioner — provided  the  labour  has  made 
any  progress — not  to  leave  the  patient’s  room  until  he  has  perfectly  satis- 
fied himself  that  it  is  the  head  which  offers  at  the  brim  : for  as  occasionally 
transverse  presentations  occur — as,  under  such  a malposition,  it  requires 
that  a change  in  the  situation  of  the  foetus  should  be  artificially  made 
before  the  birth  can  be  perfected — and  as  that  change  is  comparatively  an 
easy  operation  previously  to  the  bursting  of  the  membranes,  but  is  rendered 
one  of  the  most  difficult  in  surgery,  if  much  time  is  allowed  to  escape  after 
the  evacuation  of  the  liquor  amnii — so  it  necessarily  follows  that  the  advo- 
cates of  such  a doctrine  run  the  risk  of  lulling  their  disciples  into  a perilous 
and  fatal  security.  It  is  certainly  not  always  an  easy  matter  to  distin- 
guish the  presenting  part  at  the  onset  of  labour,  by  the  first  finger  of  the 


* Blundell’s  Principles  of  Obstctricy  by  Castle,  p.  235. 


124  natural  labour,  ( Management .) 

right  hand,  because,  occasionally,  it  lies  too  high  for  detection  in  that 
manner:  but  it  is  seldom  that  some  part  of  the  child’s  body  cannot  be  felt, 
if  two  fingers  of  the  left  hand  be  introduced  into  the  vagina  ; since  they 
will  almost  always  command  the  whole  cavity  of  the  pelvis,  and  may  be 
passed  up  to  the  very  brim.  Whenever,  then,  any  doubt  arises  as  to  the 
position  of  thp  foetus,  it  is  much  better  to  have  recourse  to  this  second 
expedient  than  to  remain  in  ignorance  of  so  material  a point. 

Discriminating  marks  of  ahead  presentation. — The  head  is  distinguish- 
able by  its  large  volume,  its  roundness  and  firmness,  and  by  its  constituent 
bones  being  intersected  and  separated  from  each  other  by  open  lines  and 
spaces : for  it  seldom,  when  the  os  uteri  is  dilated  to  the  size  of  half  a 
crown  or  a dollar,  that  we  cannot  detect  some  portion  of  a fontanelle,  or 
one  of  the  sutures.  There  is  little  chance  of  any  other  presentation  being 
mistaken  for  the  head,  except  the  breech,  and  perhaps  (as  I have  known 
happen)  the  side.  The  breech  is  most  likely  to  be  confounded  with  the 
cranium,  because  it  possesses  a larger  circumference  than  any  other  part 
of  the  child’s  body,  except  the  head  ; but  it  still  differs  from  the  head  mate- 
rially in  its  general  size,  and  more  particularly  in  feeling  to  the  finger 
softer — not  so  resistant,  but  more  cushiony : it  is  also  more  pointed,  and 
possesses  no  structure  resembling  a suture  or  fontanelle.  The  principal 
discriminating  marks  of  the  presence  of  the  breech,  however, — of  which 
I shall  speak  more  at  length  hereafter — are  the  anus  and  genitals.  The 
only  point  of  structure  in  the  side  that  bears  the  least  shadow'  of  resem- 
blance to  the  head,  consists  in  the  interosseous  spaces  between  the  ribs;  one 
of  which  might  possibly  be  mistaken  for  a cranial  suture.  If  it  were  worth 
while  drawing  distinctive  marks  between  these  two  parts,  I might  observe, 
that  at  the  commencement  of  labour  under  a side  presentation,  the. body 
of  the  foetus  seldom  descends  upon  the  brim,  or  into  the  pelvic  cavity,  so 
readily  as  when  the  head  offers  itself ; the  shoulder  and  breech  being  then 
supported  by,  and  resting  upon,  the  respective  ilia.  It  is,  therefore,  gene- 
rally quite  out  of  the  reach  of  the  finger,  until  after  the  membranes  have 
broken ; and  this  of  itself  would  be  a suspicious  circumstance.  Secondly, 
the  space  between  the  ribs  is  wider  than  any  suture  of  the  head — unless, 
indeed,  the  foetus  be  hydrocephalic ; and,  thirdly,  w?e  may  usually  detect 
more  than  one  interosseous  vacancy.  Now,  as  there  are  no  two  sutures  in 
the  cranium  that  run  in  parallel  lines,  if  we  can  trace  more  than  one  such 
space  by  the  finger,  we  can  be  at  no  loss  to  determine  that  they  are  both 
intercostal. 

Having  ascertained  by  the  marks  enumerated  that  the  head  presents, 
we  may  be  content  with  this  information ; it  is  by  no  means  necessary,  or 
desirable,  at  present,  that  we  should  perplex  ourselves  with  endeavouring 
to  make  out  the  nice  distinctions  between  the  different  parts  of  the  head, 


125 


natural  labour,  ( Management . ) 

so  as  to  say  exactly  whether  the  face  is  directed  to  one  side  or  the  other ; 
or  whether  the  vertex  presents,  or  any  other  point.  It  is  sufficient  that  we 
have  assured  ourselves  the  head  is  at  the  brim ; and  we  may  take  it  for 
granted  the  vertex  offers,  unless,  indeed,  we  can  clearly  distinguish  the 
marks  of  some  other  part.  This  recommendation  is  not  given  to  impress 
the  student  with  the  idea  that  it  is  enough  to  make  a careless  examination, 
but  to  prevent  his  doing  harm  by  any  attempts  to  inform  himself  on  such 
a difficult  matter — harm  by  irritating  the  vagina  and  os  uteri — but  espe- 
cially by  prematurely  rupturing  the  membranes,  which  it  is  highly  neces- 
sary to  preserve  whole.  For  in  irritable  habits  we  shall  often  find  that 
the  most  simple  examination  is  sufficient  to  cause  an  accession  of  uterine 
pain;  and  if — only  intent  on  ascertaining  how  the  head  is  situated,  with- 
out reference  to  the  preservation  of  the  bag — we  carry  our  finger  round, 
within  the  os  uteri,  we  shall  most  likely  induce  action  ; and  the  membranes 
will  be  more  or  less  suddenly  protruded  against  its  extremity.  The  finger 
then  passes  into  the  centre  of  the  aqueous  cyst,  the  liquor  amnii  discharges 
itself,  and  irreparable  mischief  is  done.  Let  us  then — if  we  have  clearly 
distinguished  the  head  over  the  os  uteri — presume  that  it  is  placed  in  the 
most  favourable  position  for  its  descent  into  the  cavity  of  the  pelvis,  until 
the  membranes  have  given  away.  We  may  after  that  proceed  to  examine 
the  presenting  part  more  accurately ; and,  provided  the  labour  does  not 
progress  favourably  and  satisfactorily,  wTe  must  take  pains,  in  all  cases,  to 
learn  whether  the  delay  be  owing  to  the  malposition  of  the  head ; or  to 
some  other  of  the  many  and  various  causes  that  may  retard  its  advance. 

When  the  first  examination  has  been  made,  the  patient  herself,  and 
her  friends,  are  always  anxious  to  learn  from  the  medical  attendant 
if  all  be  natural  and  satisfactory,  and  how  long  is  likely  to  elapse 
before  the  labour  will  be  terminated.  With  regard  to  the  first  ques- 
tion if  we  have  gained  all  the  information  which  I require  we  should 
do,  we  may  give  a decided  answer ; but  the  second  must  be  evaded.  If 
we  find  the  vagina  distensible,  the  os  uteri  dilated,  the  head  presenting, 
and  the  pains  sufficiently  active ; we  may  reply,  with  a positive  assurance, 
that  so  far  every  thing  is  favourable ; that  no  case  can  afford  a more 
auspicious  promise  than  the  one  under  our  care ; and  that,  therefore,  we 
are  warranted  in  anticipating  a fortunate  result : to  the  second  question, 
let  us  not  attempt  to  reply.  Let  us  take  it  for  granted,  after  such  a posi- 
tive declaration  of  good  tidings,  that  it  will  not  be  repeated;  and,  as 
society  is  at  present  constituted,  whoever  obtains  a plain,  straight-forward 
answer  to  one  out  of  two  questions,  ought  to  consider  himself  fairly  dealt 
with.  But  if  the  party  we  are  addressing  thinks  differently, — which  we 
shall  most  usually  find  the  case, — and  presses  the  subject  again  on  our 
attention,  let  us  tell  them  plainly,  they  ought  to  remain  content  with  the 


126  natural  labour,  ( Management .) 

honest  declaration  we  have  given,  that  the  case  is  progressing  as  favour- 
ably as  possible;  that  it  is  out  of  the  scope  of  human  knowledge,  and  con- 
sequently quite  out  of  the  power  of  any  human  being,  to  say  positively 
when  the  labour  will  be  terminated.  Any  opinion  we  might  form  would 
be  but  a guess  at  the  best ; and  it  is  not  fit  that  we  should  trust  an  answer, 
which  may  involve  such  serious  disappointment,  to  conjecture.  If  we 
were  to  make  a promise,  that  the  labour  would  be  brought  to  a close 
either  at  noon  or  midnight,  or  any  other  specified  moment,  we  may  be  dis- 
appointed in  two  ways.  It  is  very  unlikely  that  it  should  end  just  at  the 
period  of  time  we  have  mentioned ; it  might  be  earlier,  and  then  an  infe- 
rence might  be  drawn,  that  we  knew  nothing  about  the  case : but  it  is  also 
probable,  that  the  time  fixed  upon  will  pass  by,  without  our  promise  being 
fulfilled;  it  will  then  act  most  injuriously  on  the  patient’s  mind;  she  loses 
confidence, — -that  loss  of  confidence  is  attended  with  dejection, — the  ner- 
vous system  is  depressed, — and  the  process  of  labour  is  more  or  less  inter- 
fered with.  By  making  promises  of  this  kind,  indeed,  we  may  be  the 
means  of  producing  a lingering,  painful,  dangerous,  an  instrumental,  and 
perhaps  a fatal  case.  Upon  such  trifles,  sometimes,  does  the  welfare  of 
our  patient  depend ! 

Frequent  examinations  should  not  he  made  during  the  first  stage  of 
labour: — we  can  do  no  good  by  such  a practice,  after  we  have  oncy 
gained  the  information  we  require ; we  cannot  facilitate  the  descent  of  the 
child ; we  cannot  dilate  the  parts ; but  we  may  do  a great  deal  of  injury ; 
for  we  denude  the  vagina  of  that  soft  relaxing  mucus  which  is  designed 
by  nature  to  protect  it,  and  we  moreover  run  the  risk  of  destroying  the 
integrity  of  the  membranous  cyst : we  may,  therefore,  predispose  the  parts 
to  inflammation,  and  retard  the  dilatation  of  the  os  uteri  itself.  As,  how- 
ever, it  is  a common  idea  among  women,  that,  under  each  examination, 
material  assistance  is  rendered,  we  shall  frequently  be  urged,  during  the 
first  stage, — especially  if  the  labour  be  rather  slower  than  usual, — to  re- 
main in  close  attendance  on  the  patient’s  person ; and  these  solicitations 
are  generally  advanced  with  a degree  of  fervency  that  it  appears  the 
extreme  of  cruelty  not  to  accede  to.  Should  this  be  the  case,  the  finger 
may  be  introduced  from  time  to  time,  with  the  greatest  care  and  gentle- 
ness ; more  to  pacify  the  patient’s  mind,  and  assure  her  she  is  not  neglected, 
than  with  any  other  view  beyond  that  of  merely  watching  the  progress  of 
dilatation.  The  more  rigid  the  parts  are,  the  more  do  they  require  the 
softening  influence  of  the  natural  secretion,  and  the  more  careful  must  we 
be  to  preserve  it. 

A question  naturally  arises,  whether  we  shall  remain  in  the  bed-room, 
or  may  with  safety  return  home.  It  is  not  right  that  we  should  stay  in 
the  same  chamber  with  the  patient,  during  the  first  stage ; because  there 


127 


natural  labour,  ( Management .) 

is  a frequent  inclination  to  pass  urine  and  fseces ; and  she  will  be  compelled 
to  restrain  that  desire,  as  she  will  probably  not  like  to  be  constantly  re- 
questing her  medical  attendant  to  retire.  It  is  not  necessary  for  us  to 
remain  with  her ; all  that  is  required  being,  that  we  should  overlook  the 
process,  and  be  at  hand  to  act  on  any  emergency  occurring.  We  may 
retire,  then,  from  the  room,  and  direct  the  nurse  to  inform  us,  if  the  pains 
become  stronger,  and  particularly  if  the  membranes  rupture.  In  about  an 
hour — should  we  receive  no  summons  in  the  mean  time — we  may  see  her 
again,  and  may  then,  if  we  think  it  right,  make  another  examination,  to 
ascertain  that  the  labour  is  proceeding  satisfactorily.  But,  if  it  is  not 
necessary  for  us  to  continue  in  the  chamber,  or  by  the  bed-side,  is  it  desi- 
rable for  us  to  return  home  ? In  this  question,  the  comfort  and  conve- 
nience of  the  medical  attendant  are  much  interested;  and  its  answer  must 
depend,  in  a great  measure,  on  circumstances; — such  as,  whether  it  is  a 
first  or  subsequent  labour ; whether  the  previous  labours  have  been  quick 
or  lingering ; how  far  the  os  uteri  is  dilated  or  dilatable,  and  particularly 
the  distance  of  her  residence.  If  it  should  not  be  above  a few  minutes’ 
walk  from  one  house  to  another,  it  is  not  necessary  that  we  should  stay 
at  the  commencement  of  labour ; but  if  the  distance  be  great, — especially 
if  the  patient  have  had  children  before,  and  her  labours  have  been  quick, 
— even  should  the  os  uteri  not  be  dilated  more  than  to  admit  the  point  of 
one  finger ; provided  the  pains  are  following  each  other  rapidly,  it  is  better 
not  to  leave  the  house.  As  a general  principle,  I would  advise,  that  in  all 
cases,  as  soon  as  the  os  uteri  has  acquired  the  diameter  of  half-a-crown, 
sufficiently  large  to  admit  the  points  of  four  fingers  just  within  its  disc,  the 
attendant  should  not  be  absent  from  the  house  for  more  than  a quarter  of 
an  hour  or  twenty  minutes  at  a time ; because,  although  it  may  have  taken 
five  or  six  hours  to  dilate  from  a close  state  to  that  dimension,  the  subse- 
quent process  of  dilatation  may  go  on  so  rapidly,  that  a few  more  pains 
may  accomplish  the  delivery ; and  that  before  he  can  arrive. 

Some  practitioners  recommend,  that,  although  our  presence  is  not  re- 
quired in  the  lying-in  chamber,  still  we  should  not  occupy  ourselves  in  any 
employment  or  amusement,  while  we  remain  in  attendance.  They  argue, 
that,  inasmuch  as  we  receive  a consideration  for  our  time  and  service, 
our  whole  mind  should  be  entirely  devoted  to  the  woman’s  safety,  and  in 
suggestions  for  her  comfort.  With  this  sentiment  I entirely  disagree.  I 
grant  that  we  ought  to  afford  every  necessary  and  proper  attention,  whe- 
ther we  are  remunerated  or  not ; but,  in  common  cases,  such  an  entire 
devotion  of  our  mental  faculties  is  not  required ; and  we  may  produce  a 
hurtful  impression  by  our  apparent  anxiety.  It  is  natural  for  a man,  who 
is  not  of  an  indolent  disposition,  but  whose  mind  is  usually  directed  to 
some  object,  to  become  fidgety , if  his  attention  be  not  occupied  by  any 


128 


natural  labour,  ( Management .) 

pursuit ; he  will,  perhaps,  be  pacing  the  drawing-room,  where  the  husband 
is  sitting ; and  by  a mere  absence  of  manner,  which  he  can  scarcely  dis- 
guise, he  will  convey  an  idea  that  he  is  more  than  ordinarily  anxious  on 
account  of  the  lady.  Such  an  impression  will  find  its  way  through  the 
crevice  of  the  door  to  the  lying-in  chamber ; it  will  reach  the  invalid  her- 
self, and  is  likely  to  produce  all  the  disadvantages  which  result  from  de- 
pressed spirits.  Let  him  occupy  himself,  then,  in  some  way  that  beet 
suits  his  taste,  either  writing  or  reading ; and  there  are  few  books  he  may 
chance  to  take  up  but  will  afford  him  both  amusement  and  instruction. 

It  is  by  no  means  requisite  that  the  patient  should  continue  in  one  pos- 
ture during  the  first  stage ; she  may  relieve  herself  by  changing  her  mode 
of  lying,  by  sitting  up,  or  walking  about  the  room ; for  she  will  soon  be 
able  neither  to  sit,  stand,  nor  walk,  but  will  be  compelled  to  take  a defi- 
nite position  on  the  bed,  from  which,  in  ordinary  cases,  she  is  not  to  move 
till  after  the  termination  of  the  labour. 

She  may  be  allowed  any  bland,  fluid  nourishment,  that  she  fancies ; but 
it  is  very  little  she  requires.  The  attendants  about  her  are  usually  soli- 
citous that  she  should  take  sustaining,  or  perhaps  stimulating,  substances. 
But  these  must  be  forbidden : the  process  of  digestion  does  not  go  on  under 
labour  with  sufficient  energy  to  assimilate  solid  animal  food ; and  any 
thing  likely  to  excite  the  circulation  would  have  a tendency  to  induce 
fever.  A little  beef-tea  may  be  taken ; but  farinaceous  preparations,  or 
tea,  or  coffee,  are  much  better  ; and  we  shall  generally  find  that,  inasmuch 
as  the  digestive  process  is  almost  suspended  under  labour,  so  there  is  very 
little  desire  for  nourishment;  and  what  is  swallowed  beyond  the  simplest 
fluids,  is  more  in  compliance  with  the  entreaties  of  her  officious  friends, 
than  from  any  appetite  or  inclination  of  her  own. 

Duties  during  the  second  stage. — The  second  stage  of  labour  having 
commenced,  we  are  summoned  to  the  patient’s  bed-room,  if  we  have  been 
absent,  and  told  that  the  “ waters  have  broken.”  She  is  most  likely  found 
reclining  on  the  bed,  and  probably  the  pains  are  more  urgent  than  they 
were  before,  or  perhaps  they  are  somewhat  suspended.  We  now  require 
to  make  another  examination,  because  it  is  possible  that  the  head  may 
have  fully  entered  the  cavity,  and  may  be  soon  expelled.  Finding  it  low 
in  the  pelvis — finding  the  os  uteri  almost  entirely  dilated,  the  membranes 
broken,  and  the  pains  strong,  and  coming  on  frequently,  it  is  right  not  to 
leave  the  room ; but  unless  the  perineum  be  somewhat  on  the  stretch,  it  is 
not  necessary  for  us  yet  to  take  our  post  exactly  by  the  bed-side. 

But  as  soon  as  the  head  has  come  to  press  upon  the  external  parts, — 
particularly  when  it  has  made  its  turn,  and  is  beginning  to  extend  the 
structures  at  the  outlet  of  the  pelvis, — it  becomes  our  duty  to  take  our  seat 


129 


natural  labour,  ( Management .) 

by  the  bed-side,  and  never  to  move  from  our  position  till  the  child  has 
passed.  This  we  do  to  protect  the  perineum,  in  order  to  prevent  lacera- 
tion. 

For  the  purpose  of  supporting  the  perineum  we  sit  rather  behind  the 
patient,  and  apply  the  palm  of  the  left  hand — guarded  for  the  sake  of  deli- 
cacy, cleanliness,  and  convenience,  with  a soft  napkin — steadily  and  firmly 
against  the  perineal  tumour. 

To  give  the  required  protection,  it  is  not  necessary  that  we  should  make 
powerful  pressure,  nor  resist  the  child’s  exit  by  the  employment  of  any 
exertion ; we  are  only  to  afford  a passive  support.  Placing  our  elbow  on 
the  bedstead,  we  render  it  a fixed  point,  and  rather  allow  the  head,  covered 
by  the  thinned  structures,  to  be  protruded  against  our  hand,  than  forcibly 
press  our  hand  up  against  the  head.  This  part  of  the  duty  of  the  obste- 
trical attendant  is  sometimes  exceedingly  fatiguing.  We  may  occasionally 
be  compelled  to  remain  many  hours  by  the  side  of  the  bed,  without  moving 
from  our  seat.  It  is  not  to  be  wondered  at,  that,  under  such  an  irksome 
posture,  the  hand  should  become  numbed,  and  the  whole  body  cramped ; 
but  we  must  put  our  personal  inconvenience  quite  out  of  the  account, 
when  weighed  against  our  patient’s  safety ; and  we  must  recollect  that 
the  more  rigid  the  parts  are,  the  longer  they  take  in  dilating,  the  more 
our  assistance  is  necessary.  We  must  not  permit  any  length  of  time  that 
we  may  have  so  fatiguingly  occupied,  to  rise  as  an  excuse  for  relaxing 
in  this  duty ; but  always  bear  in  mind,  that  if  the  uterus  aet  strongly,  and 
the  head  be  protruded  suddenly,  while  the  parts  have  not  the  advantage 
of  the  support  we  can  afford,  there  is  great  danger  that  such  a degree  of 
laceration  may  occur,  as  will  perhaps  render  the  woman  miserable  for 
the  rest  of  her  existence. 

Most  women  remain  tolerably  quiet,  in  one  position,  during  the  second 
stage  of  labour  ;•  but  some  are  exceedingly  irritable,  tossing  about  in  all 
directions,  will  not  be  advised,  and  can  scarcely  be  restrained.  It  is  our 
duty  by  all  the  means  in  our  power,  both  of  persuasion  and  gentle  force, 
to  prevent  such  a patient  injuring  herself  by  suddenly  starting  away  from 
our  protection ; for  many  cases  have  happened  where  a rupture  of  the 
perineum,  under  such  circumstances,  has  occurred,  to  a frightful  extent : 
and,  by  a little  management,  we  may  generally  succeed  in  confining  her 
sufficiently.  I have  already  mentioned,  that  the  thighs  must  be  drawn  up 
towards  the  abdomen,  and  the  legs  bent  a little  back  upon  the  thighs,  the 
whole  person  lying  on  the- left  side;  and  the  patient  is  usually  placed  so 
that  her  feet  may  rest  against  the  bed-post ; and  in  this  way  they  become 
a fixed  point,  and  keep  the  pelvis  steady.  We  render  the  shoulders,  also, 
another  fixed  point,  so  as  to  steady  the  upper  part  of  the  body,  by  tying  a 
long  napkin,  or  a round  towel,  to  the  same  bed-post ; and  desiring  her  to 


130 


natural  labour,  ( Management .) 

hold  it  in  her  hand.  We  tell  her,  when  the  pain  comes  on,  to  press  with 
her  feet  against  the  bed-post ; and  pull  gently  at  the  towel,  cautioning  her 
against  straining  violently.  The  consequence  is,  she  so  fixes  her  person 
as  to  render  it  almost  impossible  for  her  to  jump  away  suddenly,  or  to 
recede  to  any  distance  from  us.  Independently  of  this  little  manoeuvring 
— when  the  head  is  in  any  degree  extending  the  vulva — the  nurse  must  be 
required  to  raise  the  right  knee  to  some  distance  from  the  other,  by  which 
means  the  thighs  are  separated,  and  an  increased  facility  given  to  the 
exit  of  the  head  through  the  external  parts,  as  well  as  some  control  exer- 
cised over  her  movements. 

It  is  very  possible  that  the  nurse  may  wish  to  substitute  a pillow  for  her 
own  services,  and  persuade  us  it  will  do  equally  as  well.  For  four 
reasons  the  pillow  must  be  objected  to ; it  increases  the  heat  of  the 
person,  already,  perhaps,  profusely  perspiring ; it  does  not  afford  a sup- 
port sufficient  to  prevent  the  legs  from  being  squeezed  together  ; in  the 
acme  of  pain  it  will  often  slip  away  from  between  the  knees,  and  we  lose 
its  advantage  just  when  we  require  it  the  most;  and  lastly,  it  can  be  of  no 
service  in  restraining  the  woman  in  one  posture. 

The  extent  of  injury  to  which  the  perineum  is  liable  varies  much  in 
degree,  from  a simple  laceration  of  one  or  two  fibres  at  the  anterior  edge, 
to  a rupture  of  the  whole  organ,  the  destruction  of  the  sphincter  ani,  and 
the  conversion  of  the  two  canals,  the  vagina  and  rectum,  into  one  com- 
mon cavity.  The  rent  generally  commences  at  the  fourchette : at  other 
times  it  will  begin  in  some  portion  of  the  inner  membrane  of  the  vagina, 
and  extend  anteriorly  to  the  edge  of  the  perineum,  when  it  will  be  again 
continued  back  through  the  integuments  to  the  point  corresponding  with 
the  origin  of  the  laceration  within,  or  will  even  pass  beyond  it ; and  more 
rarely  the  head  is  protruded  through  the  substance  of  the  perineum  itself, 
forming  a fresh  aperture,  by  which  it  escapes,  leaving  the  fourchette 
entire.  Of  this  latter  variety,  I have  only  seen  one  instance  ; and  on  that 
case  my  opinion  was  requested  in  consultation,  a few  days  after  the 
labour.  It  was  evident  there,  that  the  child  had  not  passed  through  the 
vulva,  but  through  an  adventitious  opening,  between  the  anus  and  genital 
fissure,  and  the  attendant  was  perfectly  aware  of  that  circumstance  at 
the  time.* 

Varying  much  in  time,  varying  much  in  the  intensity  of  agony  which 
is  suffered,  and  in  the  number  of  pains  that  occur,  the  head  is  at  last 
protruded,  in  the  manner  before  noticed.  It  is  most  likely  the  child 
may  attempt  to  gasp  the  moment  the  head  is  expelled;  and  on  this 
account  it  is  right  to  wipe  its  face  immediately  with  a clean  napkin,  (of 

* For  a case  of  this  kind  see  Merriman’s  Synopsis  of  Difficult  Parturition,  p.  240.  See  also 
Denman’s  Introduction  to  Midwifery,  chap,  ii.  sect.  7. 


131 


natural  labour,  ( Mayiagement. ) 

which  necessary  articles  we  always  require  to  have  a store  close  at 
hand,)  lest  in  the  first  inspiration  some  of  the  mucus  which  may  hang 
about  its  lips,  or  other  moisture,  should  be  inhaled. 

Coiling  of  the  funis  around  the  neck. — I have  already  mentioned,  that 
some  little  time  usually  elapses  between  the  expulsion  of  the  head  and  the 
pain  that  is  to  expel  the  shoulders;  and  this  interval  may  be  usefully 
employed,  after  the  face  is  cleaned,  in  making  an  examination  of  the 
neck,  to  ascertain  whether  a fold  of  funis  may  not  possibly  be  surrounding 
it,  Plate  XXVI.  fig.  84.  It  frequently  happens  that  there  is  one ; some- 
times there  are  two,  and  occasionally  three  or  four  folds  of  the  navel- 
string  coiled  around  the  neck ; and  if  it  were  not  liberated,  it  is  very 
possible  that  the  pain  which  expels  the  shoulders  might  cause  the  placenta 
to  be  dragged  away  from  its  attachment,  to  the  great  peril  of  the  mother, 
from  haemorrhage,  or  perhaps  from  inversion  of  the  uterus.  But  the  chief 
danger  is  to  the  infant.  If  on  its  expulsion  the  cord  be  drawn  tightly 
around  its  neck,  the  circulation  through  the  funis  will  be  arrested 
by  the  compression  of  the  vessels ; and  the  same  compression  may  also 
close  the  trachea  to  such  an  extent,  as  to  prevent  the  ingress  of  air  into 
the  lungs.  Thus  the  two  sources  by  which  life  is  maintained  being  cut  off 
at  the  same  time,  strangulation  must  be  a necessary  consequence.  I was 
once  witness  to  the  death  of  an  infant  under  such  circumstances.  When 
I arrived  at  the  patient’s  house,  I found  the  child  lying  dead  near  the 
external  parts  of  the  mother.  The  funis  umbilicalis  was  twice  coiled 
round  the  neck,  and  the  child  had  been  deprived  of  the  advantage  of  the 
placental  circulation,  and  of  the  power  of  breathing  at  the  same  time, 
and  by  the  same  means.  There  was  a deep  livid  ring  encircling  the 
throat,  produced  by  the  pressure  the  funis  had  caused ; and  it  was  evi- 
dent from  this  mark  that  the  infant  was  alive  at  the  moment  of  its  birth. 
It  is  a most  interesting  and  instructive  case,  not  only  obstetrically  and 
physiologically,  but  particularly  with  respect  to  forensic  medicine.  If 
this  birth  had  taken  place  under  suspicious  circumstances,  and  the  mother 
had  not  been  a married  woman,  it  is  very  possible  that  a charge  of 
murder  might  have  been  founded  on  the  appearance  of  the  mark  round 
the  neck ; as  it  could  not  be  distinguished  from  the  effects  of  a cord, 
applied  with  the  intention  of  destroying  life. 

The  best  way  to  free  the  funis  from  this  awkward  situation  is  by  draw- 
ing down  the  loop,  and  passing  it  over  the  child’s  head,  by  which  means 
we  liberate  it  entirely,  and  it  is  no  longer  an  impediment  to  the  expulsion 
of  the  shoulders.  But  it  occasionally  happens, — especially  if  the  funis  be 
more  than  once  coiled  round  the  neck, — that  it  is  not  sufficiently  long  to 
allow  its  being  pulled  over  the  head : we  may  then  keep  the  loop  distended 
with  our  fingers,  until  the  shoulders  are  expelled,  and  they  must  be  allowed 


132 


natural  labour,  ( Management .) 

to  slip  through  it.  In  some  cases  it  is  not  possible  to  carry  into  effect 
either  of  these  modes  of  liberating  the  child ; and  it  may  be  necessary  to 
cut  the  funis  before  applying  a ligature.  Under  such  a proceeding  we 
must  be  careful  to  prevent  bleeding  from  the  umbilical  arteries. 

Directly  the  head  is  born,  it  is  usual  for  some  one  of  the  attendants  to 
offer  to  the  medical  practitioner  a close  flannel  cap  for  the  infant,  which 
he  is  expected  to  apply  as  soon  as  a convenient  opportunity  occurs ; and 
this  is  done  under  the  idea  that,  of  all  parts  of  the  body,  the  head 
is  most  susceptible  of  the  action  of  cold.  As  far  as  I know,  there  is  no 
good  ground  for  this  assumption  ; but  inasmuch  as  the  custom  is  dictated 
by  a very  universal  prejudice,  it  is  as  well  to  give  way  to  it,  unless  other 
more  important  duties  require  immediate  attention : for  should  this  very 
necessary  precaution,  as  it  is  supposed,  be  omitted,  and  the  proffered 
means  of  protection  be  rejected  with  indifference  or  scorn,  it  is  more  than 
probable  that  any  little  ailments  the  child  may  be  subject  to  during  the 
first  few  weeks  of  its  extra-uterine  existence,  will  be  attributed  to  the 
neglect  shown  in  this  particular. 

Support  of  the  perineum  during  the  expulsion  of  the  body, — Although 
the  shoulders  of  the  child  take  up  less  room  than  the  head,  and  although 
the  parts,  having  been  previously  distended  by  the  passage  of  the  larger 
substance,  generally  easily  admit  the  shoulders — provided  the  child  be  of 
normal  shape — still  it  is  desirable  that  support  should  also  be  afforded  to 
the  perineum  while  the  body  is  being  protruded,  even  after  the  head  has 
made  its  exit.  Having  wiped  the  face,  and  made  an  examination  to 
ascertain  that  the  funis  is  not  twisted  around  the  neck,  we  may  again 
place  the  left  hand  on  the  perineum,  while  we  direct  the  foetal  body 
rather  forwards, — in  correspondence  with  the  axis  of  the  pelvic  outlet, — 
and  receive  it  with  the  right. 

It  used  to  be  the  custom  to  surround  the  neck  with  the  thumbs  and 
fingers  of  both  hands,  and  forcibly  extract  the  body  the  moment  the  head 
was  in  the  world,  for  the  purpose  of  liberating  the  woman  from  pain,  and 
terminating  the  delivery  as  speedily  as  possible.  Such  practice  is  attended 
with  double  danger ; — great  chance  of  injury  to  the  child,  by  the  tension 
of  the  neck ; and  no  small  probability  of  hazard  to  the  mother,  by  the 
uterus  being  prematurely  emptied.  It  is  thus  left  in  a flaccid  state:  the 
stimulus  which  previously  disposed  it  to  contract  is  suddenly  taken  away; 
that  disposition  ceases,  or  is  suspended  ; hemorrhage  is  induced  ; a neces- 
sity probably  arises  for  the  artificial  removal  of  the  placenta  ; and  incal- 
culable mischief  is  the  consequence.  Those  persons  who  commend  such 
meddling  interference,  and  who  estimate  the  skill  of  the  obstetrical 
attendant  by  the  rapidity  with  which  he  can  extract  the  body  after  the 
head  is  born,  found  their  eulogium  on  most  dangerous  premises. 


133 


natural  labour,  ( Management .) 

When  the  shoulders  have  passed,  the  parts  require  no  farther  protection  ; 
the  breech  and  legs  are  generally  soon  expelled,  with  slight  suffering,  and 
little  hazard  to  the  maternal  structures. 

The  child,  then,  being  entirely  in  the  world.,  it  must  be  slowly  removed 
a little  distance  from  the  mother’s  body,  not  more  than  to  the  extent  of 
four  or  five  inches,  and  withdrawn  from  beneath  the  bed-clothes,  the 
woman’s  person  being  still  left  perfectly  covered  and  concealed.  It  has 
been  already  shown  that  the  funis  umbilicalis  varies  exceedingly  in  length, 
and  that  sometimes  its  measure  has  been  known  not  to  exceed  half  a foot. 
Now  should  the  cord  be  unusually  short,  and  should  we  hastily  draw 
away  the  infant  to  some  extent,  we  shall  make  a pluck  at  the  placenta ; 
and  we  run  the  risk  of  tearing  it  away  from  its  attachment,  or,  perhaps, 
of  even  inverting  the  uterus.  If  we  find  the  cord  sufficiently  long  to 
permit  the  farther  removal  of  the  child’s  body,  we  may  place  it  more  com- 
pletely under  our  command  ; and  after  having  lifted  the  bed-clothes  from 
above  it,  so  as  to  bring  its  person  completely  into  view,  we  may  proceed 
to  secure  the  vessels,  and  separate  it  from  the  mother. 

The  ligatures  commonly  employed  in  London  consist  of  eight  or  ten 
pieces  of  thread,  a skein  of  which  is  placed  in  readiness  for  our  use.  A 
sufficient  number  having  been  selected  to  form  the  proper  thickness,  a 
knot  must  be  tied  at  each  end;  and  this  preparation  should  be  made 
before  the  child  is  born.  Even  in  forming  the  ligature  some  attention  is 
requisite ; if  it  be  too  thick,  it  will  not  compress  the  arteries  sufficiently  to 
prevent  bleeding  after  the  funis  is  cut ; and  it  is  also  liable  to  lose  its  hold, 
and  slip  altogether  off  the  cord,  thus  leaving  the  vessels  perfectly  unpro- 
tected : and  if,  on  the  contrary,  it  is  too  thin, — consisting  only  of  two  or 
three  threads, — it  will  probably  cut  through  the  membranes  covering  the 
cord,  as  well  as  the  coats  of  the  vessels,  themselves,  and  cause  in  this 
manner  a loss  of  blood.  It  is  also  necessary  that  the  threads  should  be 
all  of  equal  length ; for  if  one  or  two  be  shorter  than  the  rest,  they  alone 
will  make  compression ; and  consequently  they  will  act,  as  though  the 
ligature  were  composed  of  them  only. 

Two  of  these  ligatures  at  least  must  be  prepared : one  is  to  be  applied 
about  three  fingers’  breadth — two  inches — from  the  child’s  navel,  must  be 
drawn  tight,  and  strongly  secured  by  a double  knot.  A second  must  be 
placed  nearer  the  placenta,  at  about  the  same  distance  from  the  first,  that 
the  first  is  from  the  body  of  the  infant ; and  a double  knot  made  as  before: 
the  funis  is  then  to  be  divided  between  them.*  It  is  as  well,  previously  to 


* Smellie,  (vol.  i.  p.  196,)  Baudelocque,  (parag.  848,)  and  Dewees,  (parag.  485,)  recom- 
mend the  employment  of  one  ligature  only,  near  the  body  of  the  child;  and  the  reason  assigned* 
is,  that  the  escape  of  blood  from  the  open  vessels  of  that  portion  of  the  funis  left  attached  to 
the  placenta,  by  diminishing  the  bulk  of  that  mass,  facilitates  its  expulsion.  This  practice 


134 


natural  labour,  ( Management .) 

tying  this  second  ligature,  to  squeeze  as  much  of  the  blood  as  we  can  out 
of  the  space  intervening  between  the  two  up  towards  the  placenta,  lest  at 
the  moment  the  division  is  made,  some  should  be  projected  on  our  dress. 

The  object  of  the  second  ligature  is  two-fold — cleanliness  and  safety : if 
the  cord  were  cut  beyond  the  first  ligature,  without  securing  the  placen- 
tal end,  the  blood  contained  in  the  umbilical  vein  and  placental  vessels 
would  be  squeezed  out,  and  run  upon  the  floor,  or  on  our  own  clothes. 
But  especially  is  this  addition  to  be  used  as  a precaution  against  the  pos- 
sibility of  danger : for  if  the  gestation  had  been  double,  and  if  (which  is  a 
very  rare  occurrence)  the  circulations  of  the  two  children  anastomosed  in 
the  placenta  common  to  both  their  systems,  so  that  the  blood  of  each  cir- 
culated in  the  body  of  the  other  reciprocally,  it  is  possible  that  the  unborn 
child  might  bleed  to  death  through  the  divided  funis  of  the  one  already  in 
the  world ; provided  the  end  of  the  cut  vessels  were  left  unprotected.  We 
need  not  fear  that  the  woman  would  lose  any  blood  from  her  system 
through  the  open  vessels  of  the  cord,  even  although  the  placenta  remained 
attached  to  the  uterine  surface ; because  there  is  no  direct  vascular  com- 
munication between  the  uterine  arteries  and  the  umbilical  vein. 

There  is  danger  in  placing  the  first  ligature  close  to  the  body  of  the 
child,  lest  we  should  include  a portion  of  intestines  protruded  through  the 
open  umbilicus  into  the  cord — an  occurrence  by  no  means  rare — and  lest 
the  compress  should  not  be  tight  enough  to  prevent  haemorrhage,  in  which 
case  we  have  no  space  left  to  apply  another  ligature  upon ; and  there  is 
danger  also  in  dividing  the  funis  too  near  the  first  made  ligature,  lest 
it  should  slip  away  from  its  hold,  and  the  vessels  be  no  longer  secured.* 

The  funis  must  he  divided  by  a pair  of  blunt-pointed  scissors,  to  pre- 
vent the  possibility  of  the  infant  being  injured  by  the  extremities  of  the 
blades.  For  the  purpose  of  protecting  it  farther  also,  the  thumb  and  third 
finger  of  the  left  hand  must  embrace  one  portion  of  the  funis, — being 
placed  over  the  ligature  which  is  nearest  to  the  child’s  body, — while  the 
other  ligature  is  held  between  the  first  and  second  finger  of  the  same  hand; 
and  the  section  must  be  made  between  them  by  one  cut.  If  one  portion 
of  the  funis  only  be  held,  and  that  carelessly,  while  the  division  is  being 
made,  it  is  by  no  means  impossible  that  one  or  more  of  the  child’s  fingers 
or  toes  might  be  taken  off  at  the  same  time,  as  in  the  case  recorded  by 


rests  upon  erroneous  premises,  as  the  placenta  is  equally  well  thrown  off,  whether  its  ves- 
sels  are  allowed  to  bleed  or  not. 

* There  was  an  absurd  notion  formerly  prevalent  in  relation  to  the  length  of  that  portion 
of  the  funis  left  attached  to  the  child’s  body  on  its  division,  (see  Dionis’s  Midwifery,  English 
translation,  p.  298,)  whiqh  is  commented  on  by  Dr.  Graaf,  ( Amstedel : 1705,  p.  72,)  in  the 
following  words : — “ Ineptum  est  illud  obstetricum  figraentum  futurum  penem  majorem,  si 
vasa  umbilicalia  non  prdximd  ad  umbilicum  ligentur.” 


135 


natural  labour,  ( Management. ) 

Merriman  ;* * * §  or  the  penis  even  might  be  amputated,  as  occurred  in  an 
instance  that  came  under  Denman’s  observation,  and  which  he  used  to 
detail  in  his  lectures.f  It  will  be  impossible  for  an  accident  of  this  disas- 
trous kind  to  happen,  if  we  protect  the  child’s  body  as  just  recommended  ; 
for  should  it  throw  a limb  into  the  very  jaws  of  the  scissors  at  the  mo- 
ment we  are  about  to  close  them,  we  shall  feel  the  stroke  upon  our 
hand,  and  become  conscious  of  the  chance  of  injury. 

Generally  the  infant  cries  strongly  as  soon  as  it  is  born,  and  in  such 
case  the  ligatures  may  be  applied  immediately.  It  was  once  the  custom 
to  tie  the  funis  directly  the  child  was  in  the  world,  yvhether  breathing  had 
commenced  or  not ; under  such  management,  no  doubt,  many  were  lost. 
Hippocrates, { speaking  of  a foetus  that  has  passed  with  difficulty,  or  been 
extracted  by  art,  counsels  us  not  to  separate  it  from  the  mother  until  it 
had  either  passed  urine,  sneezed,  or  cried  aloud ; or,  in  other  words,  until 
strong  assurance  was  afforded  of  its  having  assumed  some  of  the  functions 
belonging  to  breathing  life.  Denman§  recommends  that  we  should  not 
put  a ligature  on  the  funis  until  after  the  circulation  through  the  umbilical 
vessels  has  ceased.  Of  these  instructions,  that  by  Hippocrates  is  by  far 
the  best.  There  is  no  necessity  to  wait  until  the  umbilical  vessels  have 
ceased  to  pulsate ; because  the  same  changes  will  take  place  in  the  arterial 
system  of  the  child,  whether  the  circulation  in  the  funis  is  interrupted 
rapidly,  or  whether  it  occurs  more  slowly,  and  by  degrees ; and  the  infant 
can  derive  no  benefit  from  a continuance  of  the  circulation  through  the 
cord  after  it  has  breathed  freely,  nor  indeed  after  the  placenta  is  separated 
from  its  uterine  attachment.  Denman  tells  us,  “ in  the  course  of  ten  or 
twenty  minutes,  or  sometimes  longer,”  the  pulsation  in  the  funis  has  en- 
tirely ceased.  I am  inclined  to  think  it  would  generally  be  much  longer; 
but  this  is  mere  speculation,  as  I have  no  experience  on  the  subject ; for  I 
never  delay  the  application  of  the  ligature  until  the  pulsation  has  ceased 
spontaneously.  It  appears  to  me,  indeed,  by  such  a practice  we  should 
be  unnecessarily  keeping  the  child  in  a very  awkward,  not  to  say  danger- 
ous situation,  and  subjecting  the  mother  also  to  considerable  additional 
inconvenience.  The  rule  I would  lay  down  for  the  guidance  of  the  stu- 
dent is  nearly  that  directed  by  Hippocrates.  I would  recommend  him 
not  to  put  the  ligature  around  the  funis  until  the  child  has  cried,  or  given 


* Synopsis  of  Difficult  Parturition,  p.  21.  Here  one  joint  of  the  little  finger  was  included 
in  the  ligature  and  cut  off.  ^ 

t See  Introduction  to  Midwifery,  chap.  viii.  sect.  9,  where  the  cadfe  is  hinted  at,  though  not 
detailed. 

t De  Superfoetatione,  caput  5.  I do  not  quote  Hippocrates  as  an  obstetrical  authority;  but 
his  remark  is  valuable,  as  showing  the  practice  of  his  time. 

§ Chap.  ix.  sect.  9. 


136 


natural  labour,  ( Management .) 

some  other  unequivocal  evidence  of  the  proper  change  having  taken 
place  in  the  function  of  the  lungs ; unless  indeed  it  be  born  with  animation 
suspended,  and  he  is  desirous  of  using  the  warm  bath,  inflation  of  the 
lungs,  and  other  resuscitating  means,  as  speedily  as  possible.* 

* When  the  child  does  not  breathe  immediately  on  its  birth,  it  is  sometimes  difficult  to  ascer- 
tain whether  it  is  actually  dead,  or  its  animation  is  only  for  a time  suspended.  Animation 
may  be  suspended  by  many  causes : immediate  loss  of  blood,  sustained  by  the  mother,  as  well 
as  pressure  on  the  head,  or  on  the  funis  umbilicalis,  will  produce  the  effect ; but  it  more  fre- 
quently results  from  the  latter  than  either  of  the  former  causes.  This  pressure  may  be  the 
consequence  of  the  funis  falling  down  by  the  side  of  the  head  ; or  of  the  gravid  uterus,  by  its 
action,  squeezing  it  between  its  own  parietes  and  the  foetal  body.  Whenever,  then,  a child 
does  not  attempt  to  breathe  soon  after  it  is  born,  we  should  endeavour  to  ascertain  whether  it 
is  really  dead,  or  whether  animation  is  only  suspended  for  the  moment.  This  may  usually  be 
known  by  placing  the  hand  over  the  region  of  the  heart;  and  if  there  be  the  least  tremulous 
pulsation  observed,  it  should  be  taken  as  an  indication  that  the  child  may  be  saved.  A newly- 
born  infant  is  exceedingly  tenacious  of  life,  and  many  children  have  been  recovered,  by  the 
use  of  proper  means,  who  would  inevitably  have  perished  under  less  careful  management. 
Often,  too,  a state  of  deep  stupor,  owing  to  the  compression  the  brain  has  suffered  during  the 
passage  of  the  head,  prevails  fbr  a little  after  birth,  which,  unless  removed,  might  terminate 
in  death : for,  while  it  lasts,  the  nervous  system  is  not  susceptible  of  those  impressions  necessary 
to  induce  the  first  act  of  breathing  life.  The  child  may  then  frequently  be  roused  by  two  or 
three  smart  slaps  on  the  buttocks,  back,  and  chest ; and,  on  its  being  awakened  from  its 
lethargic  state,  a sob  will  be  drawn ; this  will  end  in  a cry,  and  respiration  will  be  established. 
This  simple  expedient  will  of  itself  often  be  found  sufficient,  without  the  employment  of 
any  other  resuscitating  measures. 

Should  this,  however,  fail  to  excite  the  first  respiratory  effort,  provided  the  heart’s  action 
Be  too  feeble  to  propel  the  blood  through  the  navel-string, — the  separation  should  be  effected 
as  speedily  as  possible,  and  the  child  entirely  immersed  in  a warm  bath.  Whenever  we  are 
attendant  upon  a case  of  lingering  labour,  or  one  complicated  with  haemorrhage,  or  any  other 
accident  after  which  it  is  probable  that  the  infant  may  be  born  with  impaired  vitality,  it  is 
right  that  we  should  have  in  readiness  a small  tub,  or  pan,  with  a sufficient  supply  of  hot  and 
cold  water,  that  a bath  of  proper  temperature  may  be  made  instantly.  We  shall  frequently 
find  that  the  stimulus  of  warmth  applied  to  the  skin  will  excite  the  respiratory  organs.  The 
temperature  should  be  ninety-seven  or  ninety-eight  degrees.  But  if,  after  a few  minutes,  the 
child  does  not  gasp,  and  we  observe  that  the  heart  is  acting  less  forcibly  than  before  the  bath 
was  had  recourse  to,  its  continuance  in  the  warm  water  will  do  no  harm  both  negatively  and 
positively  ; — in  a negative  manner,  because  it  prevents  our  calling  to  our  aid  other  more  effica- 
cious means ; and  positively,  because  the  warmth — when  the  powers  are  reduced  to  a certain 
point  of  depression  from  some  particular  causes — seems  to  act  injuriously  on  the  nervous 
system ; for  it  has  been  proved  experimentally,  that  many  animals  will  drown  much  quicker 
in  warm  than  in  cold  water.  If  this  be  granted,  it  is  probable  that  a corresponding  injurious 
effect  may  be  produced  on  the  body  of  an  infant  under  the  peculiar  state  of  asphyxia  we  are 
now  considering.  The  next  means  to  be  used,  then,  is  artificial  inflation  of  the  lungs ; by 
which  we  keep  up,  for  a time  at  least,  the  heart’s  action. 

A hot  flannel,  or  blajaket,  must  be  prepared : the  child  should  be  taken  out  of  the  bath;  the 
surface  rapidly  wiped  as  dry  as  possible;  a bit  of  clean  flannel  should  be  placed  over  its  face ; 
the  nostrils  may  be  squeezed  together  with  the  thumb  and  finger ; and  we  should  blow  into 
its  mouth  with  our  own,  alternately  inflating  the  lungs  and  depressing  the  chest.  The  flannel 
is  merely  useful  for  the  sake  of  cleanliness ; it  is  by  no  means  absolutely  necessary,  but  it  does 
no  hg.rm,  and  it  is  as  well  that  something  should  be  interposed  between  the  child’s  mouth  and 


137 


natural  labour,  ( Management .) 

On  the  child  being  separated,  it  must  be  handed  to  a careful  attendant; 
and  we  must  be  watchful  that  its  mouth  and  nostrils  are  not  so  covered 
as  to  impede  the  ingress  of  air  into  its  lungs,  an  accident  not  unlikely  to 
happen  from  the  too  zealous  attention  of  its  new  protectress  to  prevent  its 
taking  cold. 

The  infant  being  carefully  disposed  of,  we  must  pass  our  hand  upon 
the  patient’s  abdomen,  before  we  leave  our  seat,  for  the  purpose  of 
ascertaining  whether  there  be  a second  child  or  not ; and  whether  the 
placenta  is  still  retained  within  the  uterus,  or  has  escaped  into  the  vagi- 
nal cavity. 

If  the  uterus  contain  another  foetus,  its  fundus  will  be  felt  high  up, 


our  own.  Some  practitioners  recommend  that  we  should  always  be  furnished  with  a tracheal 
pipe,  by  which  the  lungs  may  be  more  perfectly  inflated  than  with  the  mouth  alone.  The  only 
objection  which  can  be  made  to  the  use  of  a pipe  is  the  difficulty  in  its  introduction  through 
the  rima  glottidis,  and  the  consequent  loss  of  much  important  time.  It  is  much  more  apt  to 
pass  into  the  oesophagus  than  the  trachea,  and  embarrass  the  operator ; if,  however,  he  has 
acquired  a certain  degree  of  dexterity  in  its  introduction,  and  can  employ  it  without  delay,  the 
lungs  are  more  likely  to  be  efficiently  filled  by  its  aid  than  without  it.  For  myself,  I have 
often  restored  newly-born  children  in  the  more  simple  manner  just  recommended;  for  although 
some  air  will  certainly  pass  through  the  oesophagus  and  distend  the  stomach,  still  a large 
quantity  will  also  find  its  way  into  the  lungs ; and  although  the  abdomen  becomes  somewhat 
tumid,  that  does  not  interfere  with  the  proper  descent  of  the  diaphragm,  nor  produce  more 
than  momentary  inconvenience;  and  certainly  this  slight  embarrassment  to  full  respiration  is 
not  to  be  put  in  competition  with  the  chance  of  restoration  that  the  process  of  inflation  affords. 

Provided,  however,  still  the  child  does  not  breathe  naturally,  while  the  heart  continues  to 
act,  as  is  often  the  case,  we  may  then  rub  a little  spirit  on  its  chest,  and  back,  and  shoulders ; 
and  we  may  irritate  the  glottis  also,  by  letting  a drop  or  two  of  spirit  fall  on  it  from  the  tip  of 
our  finger.  This  will  often  produce  a convulsive  sob,  which  may  be  the  commencement  of 
the  respiratory  process.  Our  efforts  must  be  kept  up  with  perseverance,  while  there  is  the 
least  quivering  motion  perceptible  along  the  cardiac  region  ; for  it  is  proved,  beyond  a question, 
that  in  many  animals  the  heart  has  been  kept  in  action,  by  inflation  of  the  lungs,  long  after 
death  had  unequivocally  taken  place.  Thus  Le  Gallois  kept  up  the  heart’s  action  in  rabbits 
for  many  minutes,  and  even  some  hours,  after  he  had  taken  off  the  head — the  vessels  having 
been  previously  secured — by  alternately  inflating  and  compressing  the  lungs  ; and  Sir  B. 
Brodie  has  also  shown  that  in  small  animals  artificial  respiration  will  support  the  circulation 
of  the  blood  for  some  time  after  the  heads  of  the  animals  had  been  cut  off.  These  experiments 
disprove  the  assertion  of  BichAt,  which  he  maintained,  apparently  on  theoretical  grounds  only, 
that  inflation  can  never  restore  circulation  that  has  once  ceased  ; but  is  effectual  only  in  those 
instances  where  the  heart  still  pulsates,  but  propels  mere  venous  blood.  Hence,  however 
unpromising  the  case  may  be,  it  is  our  duty,  whenever  there  is  the  least  indication  of  the 
heart  not  being  completely  at  rest,  to  use  the  most  vigorous  means  for  the  purpose  of  restoring 
its  full  powers. 

It  appears  to  me  that  this  subject  has  not  been  regarded  by  medical  men  with  the  attention 
that  it  deserves.  But  a paper  will  be  found  in  the  fifteenth  number  of  the  Provincial  Medical 
and  Surgical  Journal, — a work  which,  from  the  acknowledged  talent  and  deep  learning  of  the 
editors,  must  prove  a valuable  addition  to  the  periodical  medical  literature  of  the  present  age, — 
from  the  pen  of  Mr.  Toogood,  exemplifying  the  advantage  derived  from  a steady  perseverance 
in  inflation,  with  the  sentiments  expressed  in  which  I perfectly  coincide. 

18 


13S  natural  labour,  ( Management .) 

above  the  umbilicus,  and  its  general  bulk  will  be  almost  as  great  as  it  was 
before  the  expulsion  of  the  first.  We  shall  be  able  to  define  it  distinctly  ; 
it  will  present  that  peculiar  elasticity.,  and  that  degree  of  subdued  fluctua- 
tion, which  are  so  characteristic  of  the  gravid  uterus  towards  the  close  of 
pregnancy.  But  if  there  is  no  other  child  in  the  cavity,  we  may  find  the 
womb  in  one  of  the  following  five  conditions.  First,  it  may  be  almost  as 
small  and  hard  as  a foetal  head,  so  that  we  can  grasp  its  body  completely; 
and  it  feels  nearly  as  solid  as  a cricket-ball.  Secondly,  it  may  be  almost 
equally  small,  but  softer ; so  that  when  we  press  it,  it  gives  under  our 
hand,  and  has  somewhat  of  a doughy  feel.  Thirdly,  it  may  be  about  the 
same  size,  but  one  minute  hard  and  the  next  soft.  Fourthly,  it  may  be 
almost  as  large  as  an  adult  head,  and  so  hard  that  we  can  perfectly  define  it 
with  the  hand ; it  bears  the  character  of  a large,  solid  tumour.  And,  fifthly,  it 
may  be  as  large  as  an  adult  head,  and  soft,  its  general  volume  not  so  easily 
defined,  also  communicating  a doughy  sensation  to  the  touch ; and  when 
grasped,  it  becomes  harder  in  substance,  and  less  in  bulk. 

The  first  three  states  announce  that  the  placenta  has  wholly,  or  almost 
wholly,  passed  into  the  vaginal  cavity,  and  the  two  last  indicate  that  it  is 
still  in  utero ; the  fourth  proves  that  the  uterus  is  contracted  around  the 
mass,  and  the  fifth  shows  that  it  has  not  yet  taken  on  itself  the  office  of 
contraction,  for  the  purpose  of  expelling  it.  Of  all  these  conditions  imme- 
diately after  the  child  is  disposed  of,  we  generally  find  the  last  the  most 
prevalent — namely,  where  the  uterus  has  not  yet  contracted  to  expel  it ; 
but  where  we  may  expect  that  in  a few  minutes  action  will  be  re-esta- 
blished, under  which  it  will  be  protruded  into  the  vagina.  The  woman 
cannot  be  considered  in  a secure  state  so  long  as  the  placenta  is  retained  in 
the  uterus ; nor  is  she  to  be  looked  upon  as  positively  safe  from  hmmor- 
rhage,  unless  the  first  of  these  varieties  obtain, — unless  the  uterus  is  as 
small  as  a foetal  head,  and  so  hard  that  we  can  make  no  impression  upon 
it  by  our  grasp.  We  may  then  conclude  that  the  placenta  is  entirely 
excluded,  and  that  she  is  free  from  the  danger  of  flooding,  at  any  rate  for 
the  present:  but  this  state  of  perfect  contraction  is  seldom  met  with  so 
soon  after  the  child’s  birth. 

After  having  examined  the  uterus  through  the  parietes  of  the  abdomen, 
we  must  make  an  internal  examination,  more  perfectly  to  assure  ourselves 
in  what  way  the  placenta  is  disposed  of. . Twisting  the  funis  umbilicalis 
around  the  first  two  fingers  of  the  left  hand,  and  bringing  it  to  its  bearing, 
we  pass  the  first  finger  of  the  right  hand,  previously  anointed,  into  the 
vagina,  as  in  a common  examination.  If  the  placenta  be  entirely  in  utero, 
which,  as  just  remarked,  is  most  commonly  the  case  immediately  after 
the  child’s  expulsion,  we  shall  either  not  be  capable  of  touching  it  at  all, 
or  if  it  be  within  reach,  we  shall  only  be  able  to  detect  a very  small  por- 


REMOVAL  OF  THE  PLACENTA. 


139 


tion  of  it ; we  may  just  feel  it  offering  itself  at  the  os  uteri,  but  we  cannot 
surround  its  volume,  nor  can  we  probably  discover  the  insertion  of  the 
funis. 

Removal  of  the  placenta. — There  is  no  part  of  natural  labour  which 
requires  so  much  judgment  as  the  conduct  of  the  third  stage;  for  the 
slightest  mismanagement  of  the  placenta  may  be  productive  of  most 
serious  mischief,  by  converting  a perfectly  natural  into  a most  dangerous 
and  complicated  case.  As  long,  then,  as  the  placenta  remains  in  utero, 
so  long  we  must  wait,  within  a certain  limit, — provided  there  be  no  flood- 
ing,— for  those  contractions  which  are  to  expel  it  from  the  uterus  into 
the  vaginal  cavity.  The  length  of  time  which  it  is  desirable  to  wait 
will  be  particularly  specified  when  the  undue  retention  of  this  mass  is 
treated  of. 

Before  quitting  our  post  at  the  patient’s  bed-side,  her  person  must  be 
made  as  comfortable  as  circumstances  will  permit,  by  the  removal  of  all 
the  wet  and  soiled  napkins,  and  the  application  of  two  or  three  others, 
warm  and  dry,  to  the  hips  and  vulva,  We  need  not  be  solicitous  about  get- 
ting the  placenta  away  soon;  all  pulling  or  jerking  at  the  funis  with  this 
intent  must  be  avoided  ; but  while  it  remains  out  of  the  reach  of  the  finger, 
provided  there  be  no  return  of  pain,  some  gentle  grasping  pressure  may 
be  made  on  the  uterine  tumour;  this  will  facilitate  contraction,  and  perhaps 
expedite  the  expulsion  of  the  mass.  The  amount  of  pressure  must  not  be 
such  as  to  give  pain,  but  only  a comfortable  support  and  a sensation  of 
security.  Having  withdrawn  from  the  bed-side,  and  paid  some  little 
regard  to  the  arrangement  of  our  own  dress,  we  may  offer  some  words  of 
consolation  and  congratulation  to  the  patient ; make  our  observations  on 
the  pulse ; and  request  another  blanket  may  be  thrown  over  her,  to  prevent 
any  rigor  or  chilly  feeling  supervening  on  the  violent  perspiration  she  has 
suffered. 

In  some  countries,  and  in  parts  of  this  kingdom,  it  is  the  custom  to  give 
the  patient  a tolerably  strong  stimulant  or  cordial,  consisting  of  a glass  of 
warm  wine  or  spirit  and  water,  immediately  after  the  child’s  birth  ;*  but 
in  London  this  practice  is  not  generally  followed ; and  I think  we  act  more 
safely  in  omitting  it,  unless  faintness  or  some  other  cause  indicates  the 
necessity.  Any  mucilaginous  or  diluent  drink  may  be  exhibited,  if  she  be 
inclined  to  take  it — not  warmer,  however,  than  the  temperature  of  the 
body; — and  we  may  assure  her,  unless  there  be  any  contra-indicating  sys- 
tem, that  so  far  she  is  safe  for  the  present. 

The  nurse  should  be  required  to  devote  herself  entirely  to  her  mistress 


* Campbell’s  Mid.  p.  198. 


140 


NATURAL  LABOUR., 


until  after  the  placenta  has  passed,  because  her  services  may  be  neces- 
sary; the  child  need  not  as  yet  engage  any  part  of  her  attention.  We 
may  employ  ourselves  in  the  patient’s  room  for  five  or  ten  minutes,  if  we 
choose,  or  we  may  withdraw  into  another ; but  we  must  on  no  account 
leave  the  house  so  long  as  the  after-birth  is  unexpelled ; and  we  must  not 
be  many  minutes  together  absent  from  her  side,  lest  a sudden  attack  of 
haemorrhage  should  occur,  and  only  be  detected  on  the  supervention  of 
syncope.  Our  time  may  be  advantageously  occupied  in  looking  to  the 
child’s  safety,  and  particularly  in  assuring  ourselves  of  the  security  of  the 
umbilical  vessels. 

While  we  are  thus  watching,  we  shall  most  likely  be  informed  of  the 
return  of  uterine  action,  by  the  woman  complaining  of  two  or  three  com- 
paratively trifling  pains  affecting  the  back  and  loins.  As  it  is  probable 
that  under  these  pains  the  placenta  may  have  somewhat  descended,  ano- 
ther examination  may  then  be  made  per  vaginam  to  satisfy  ourselves  on 
this  point.  Our  subsequent  conduct  must  be  regulated  entirely  by  the 
situation  in  which  the  placenta  may  be  found.  I have  already  said,  that 
so  long  as  the  mass  remains  perfectly  out  of  the  reach  of  the  finger,  so 
long  it  is  completely  included  within  the  uterus,  and  so  long  no  attempt 
must  be  made  to  remove  it  by  traction  at  the  funis.  But  although  we  may 
be  positive,  if  we  cannot  feel  it,  that  it  has  not  yet  descended  into  the 
vaginal  cavity,  we  cannot  be  equally  certain,  when  we  detect  a portion  of 
it,  that  it  is  wholly  excluded  from  the  uterus ; because  part  of  the  edge 
may  appear  externally  to  the  os  uteri,  while  the  great  mass  remains 
within.  Neither  must  we  feel  satisfied  that  it  is  lying  loose  in  the  vagina, 
even  although  we  may  be  able  to  distinguish  the  insertion  of  the  funis 
easily,  as  is  generally  taught  and  believed,  because  the  placenta  may  be 
of  a battledore  formation ; Plate  XVIII.  fig.  64  ; and  although  the  root  of 
the  cord  may  be  quite  within  reach,  and  the  division  of  its  vessels  per- 
fectly and  clearly  discernible,  yet  the  principal  bulk  may  be  still  in  utero, 
and  perhaps  morbidly  adherent  to  the  uterine  surface;  under  which  state, 
if  we  were  to  make  any  forcible  attempts  to  remove  it  by  pulling  at  the 
cord,  we  must  necessarily  and  inevitably  produce  mischief,  and  should 
probably  place  our  patient’s  life  in  imminent  hazard. 

Before  we  can  assure  ourselves  that  the  placenta  is  totally  excluded 
from  the  uterine,  and  resting  in  the  vaginal  cavity,  we  must  be  able  not 
only  to  feel  its  substance  distinctly, — not  only  clearly  to  detect  the  inser- 
tion of  the  cord  into  its  structure,  but  wre  must  also  be  able  to  surround 
it  entirely  by  the  finger,  so  as  to  encompass  its  principal  bulk.  It  may 
then  be  withdrawn  at  pleasure  by  simple  traction  at  the  cord.  Should  it 
be  found  requisite,  however,  to  remove  it  from  the  uterus,  the  agency  of 


REMOVAL  OF  THE  P L A C E N T A. 


141 


the  funis  must  by  no  means  be  relied  on ; but  the  hand  must  be  introduced 
completely  within  the  womb,  and  it  must  be  extracted  in  the  manner  to 
be  hereafter  particularly  detailed. 

By  some,  indeed,  we  are  recommended  not  to  withdraw  the  placenta 
even  from  the  vagina,  but  to  wait  for  its  natural  extrusion  by  the  muscu- 
lar powers  of  that  organ,*  under  the  belief,  that  its  continued  residence 
in  the  canal  will  stimulate  the  uterus  to  more  perfect  and  complete 
contraction,  and  thereby  farther  the  prevention  of  haemorrhage.  I can 
neither  coincide  with  this  sentiment,  nor  agree  with  the  practice ; be- 
cause, as  already  shown,  the  vagina  having  been  inordinately  distended 
by  the  head  of  the  child,  its  fibres  will  sometimes  not  recover  sufficient 
tone  to  contract  effectually  on  the  mass  for  some  hours.  During  this 
time  the  patient’s  mind  is  kept  in  a state  of  great  anxiety,  inducing 
perhaps  serious  distress;  since  all  women  are  well  aware  that  they 
cannot  be  pronounced  safe  until,  at  any  rate,  the  after-birth  has  come 
away.  Again,  so  far  from  considering  the  continuance  of  the  placenta 
in  the  vaginal  cavity  likely  to  prevent  an  immoderate  loss  of  blood,  I 
cannot  help  thinking  that  its  tendency  would  be  exactly  the  reverse ; for, 
should  more  blood  than  is  usual  be  poured  out  by  the  uterine  vessels, 
provided  the  vagina  be  free  and  unoccupied,  it  will  escape  externally, 
give  an  opportunity  for  the  uterus  to  contract,  and  its  flow  will  be  both 
evident  to  the  woman’s  sensations,  and  perceptible  to  the  attendants,  on 
an  inquiry  being  instituted : sufficient  time  will,  therefore,  be  afforded  for 
employing  means  to  ensure  perfect  and  permanent  contraction  of  the 
organ.  If,  on  the  contrary,  the  same  disposition  existed,  while  the  pla- 
centa occupied  the  vagina,  by  filling  up  the  cavity  it  would  act  as  a plug, 
prevent  the  escape  of  blood  externally,  and  cause  an  accumulation  in  the 
uterus : that  accumulation  will  distend  the  uterine  parietes ; and,  in  the 
same  degree  as  this  distention  takes  place,  will  the  vessels  be  enlarged, 
and  their  apertures  opened.  They  will,  therefore,  be  pouring  out  their 
contained  blood  in  a geometrically  increasing  ratio,  in  proportion  as  the 
volume  of  the  uterus  becomes  expanded.  A greater  quantity  of  blood  is 
thus  lost  in  a shorter  space  of  time,  and  the  effect  is  consequently  the 
more  dangerous.  Besides,  the  blood  being  pent  up  within  the  uterine 
cavity,  there  is  no  external  evidence  of  the  danger  that  is  stealing 
onward ; and  the  patient  might  possibly  flood  to  death  before  it  was  even 
discovered  that  bleeding  was  going  on. 

No  harm  can  arise  from  withdrawing  the  placenta  carefully  from  the 
vagina  by  gentle  traction  at  the  cord,  when  it  is  entirely  under  the  com- 
mand of  the  finger,  introduced  as  before  recommended ; but  the  greatest 


* See  Denman,  lto  edit.  p.  271. 


142 


NATURAL  LABOUR. 


possible  hazard  may  be  incurred  by  attempts  to  bring  it  away  in  the  same 
manner,  before  the  mass  can  be  clearly,  distinctly,  and  perceptibly 
defined. 

The  removal  of  the  placenta  from  the  vagina  is  very  easily  effected. 
Twisting  the  funis  umbilicalis  two  or  three  times  around  the  first  and 
second  finger  of  the  right  hand,  we  draw  down  in  a line  tending  towards 
the  coccyx,  and  receive  it  in  the  left,  placed  under  the  perineum  ; or  we 
may  introduce  the  two  fingers  and  the  thumb  of  the  left  into  the  vagina, 
embrace  the  mass  between  them,  squeeze  it  as  we  would  a sponge,  and 
slowly  extract  it. 

It  is  not  only  necessary  that  we  should  remove  the  placenta,  but  the 
whole  of  the  membranes  also,  if  possible.  Some  practitioners  are  care- 
less about  the  membranes,  their  whole  attention  being  directed  to  getting 
away  the  placenta;  but  unless  some  management  be  used,  the  delicate 
foetal  involucra  are  often  torn — pieces  are  left  in  the  uterus,  giving  rise  to 
many  evils — the  least  of  which,  perhaps,  is  the  alarm  likely  to  be  created 
by  a portion  being  protruded  through  the  external  parts  in  the  shape  of  a 
thread,  or  offering  itself  across  the  vulva,  like  a smooth  glistening  tumour, 
retaining  behind  it  a quantity  of  fluid  and  coagulated  blood,  some  hours 
after  the  termination  of  the  labour. 

Another  distressing  evil  likely  to  arise  from  the  same  cause,  is  the 
accession  of  violent  after-pains,  induced  by  the  irritation  that  the  presence 
of  a portion  of  the  membranes  occasions ; and  a third,  still  more  danger- 
ous, is  fever  of  a typhoid  type,  originating  in  the  absorption  of  the  fluids 
which  are  entangled  within  their  folds,  and  which  in  time  become  putrid. 
All  these  serious  inconveniences  may  be  prevented  by  a careful  removal 
of  the  membranes. 

To  obviate  the  chance  of  their  being  torn,  some  recommend  that,  as 
soon  as  the  placenta  has  passed  through  the  os  externum,  it  should  ,be 
twisted  round  two  or  three  times,  in  such  a manner  as  to  bring  them 
away  like  a cord.*  This  is  scarcely  necessary;  all  that  is  required 
being,  that  we  should  draw  them  forth  slowly ; or  carefully  work  them 
out  with  our  fingers,  if  there  be  any  difficulty  in  their  extraction. 

The  placenta  and  membranes  being  perfectly  freed,  we  require  a basin 
or  some  other  receptacle  to  deposite  them  in,  which,  for  the  sake  of 
decency,  we  cover  with  a cloth,  and  again  apply  the  hand  over  the 
uterine  tumour,  to  ascertain  that  the  organ  is  still  in  a contracted  state, 
and  that  no  bleeding  is  going  on  into  its  cavity.  Having  perfectly  satis- 
fied ourselves  on  this  point,  we  may  a second  time  take  away  the  napkins 
soiled  with  the  accumulated  discharges,  and  envelop  the  lower  part  of 

* Campbell’s  System  of  Midwifery,  p.  302.  Die  wees’  Mid.  par.  186. 

I 


143 


natural  labour,  ( After  Treatment. ) 

the  patient’s  person  in  others  that  are  warm  and  dry.  Three  will  be 
sufficient:  one  must  be  partially  slid  under  the  left  hip;  another  may  be 
placed  over  and  around  the  right  hip ; and  a third  carried  between  the 
thighs,  directly  on  the  vulva.  After  the  patient  has  been  thus  made  as 
comfortable  as  circumstances  admit  of,  the  state  of  the  uterus  must  be 
again  inquired  into,  by  the  hand  externally  applied,  before  we  withdraw 
from  the  chamber;  and  if  no  relaxation  in  its  parietes  has  occurred,  no 
increase  in  its  volume,  nor  any  distention  of  its  cavity, — while,  at  the 
same  time,  there  is  but  little  sanguineous  discharge  externally, — we  may 
pronounce  her  safe  for  the  present  from  the  chance  of  haemorrhage ; and, 
if  other  symptoms  correspond,  in  as  favourable  a state  as  could  be 
hoped  for. 

After  Treatment. — Medicine. — It  is  the  custom  of  some  practitioners 
to  give  a large  dose  of  laudanum  immediately  after  delivery,  to  quiet  the 
system,  to  lull  the  excitement,  to  still  the  after-pains,  and  to  procure 
sleep.*  I hold  this  practice  as  a principle  to  be  even  more  injurious  than 
the  exhibition  of  large  doses  of  stimuli,  because,  besides  acting  as  a strong 
stimulus  for  the  moment,  opium  exerts  a powerful  narcotic  effect  after- 
wards ; and  by  this  effect,  it  must  interfere  with  those  proper  and  indis- 
pensable contractions  which  the  uterus  is  taking  on  itself.  It  is  true  we 
can  relieve  the  patient  from  the  annoyance  of  after-pains ; but  at  the  same 
time  that  we  remove  the  pain,  we  are  incurring  danger;  we  are  cramping 
nature,  by  depriving  her  of  the  only  power  she  possesses  for  ensuring  the 
woman’s  continued  safety.  The  same  objections,  indeed,  do  not  apply  to 
opiates  in  a small  quantity ; they  are,  in  minute  doses,  likely  to  do  good 
rather  than  injury,  because  they  may  soothe  irritability  without  interfering 
with  the  necessary  changes  going  on  in  the  uterine  system.  If,  then,  we 
can  give  such  doses  of  opium,  and  repeat  them  at  such  intervals,  as  will 
just  induce  a state  of  gentle  quietude,  and  yet  not  suspend  the  uterine  con- 
tractions, we  shall  be  rendering  the  best  service  in  our  power.  It  appears 
to  me,  that  by  the  exhibition  of  four,  five,  or  six  minims  of  laudanum,  or 
a corresponding  quantity  of  any  other  sedative  drug,  repeated  every  four 
or  six  hours,  we  shall  be  most  likely  to  effect  this  object.  The  opiate  may 
be  added  to  a saline  draught,  containing  three  or  four  drachms  of  the 
liquor  ammonise  acetatis,  with  a little  camphor  mixture,  or  given  in  any 
other  suitable  vehicle.! 

* See  Blundell’s  Obstetricy,  by  Castle,  p.  729;  Ryan’s  Manual,  1828,  p.  251. 

t Medicine  of  any  kind  may  often  not  be  required  after  delivery;  but  in  many  cases  it  is 
useful;  and  in  few  can  even  opium  do  harm,  if  exhibited  in  small  quantities,  unless  there  exist 
a peculiar  idiosyncracy  of  constitution  unfavourable  to  its  action.  It  is  as  well,  then,  that 


> 


144 


natural  labour,  ( After  Treatment .) 

Before  the  house  is  left,  it  is  right  to  make  another  examination  of  the 
uterus,  through  the  parietes  of  the  abdomen,  to  ascertain  that  it  has  not  be- 
come relaxed  since  the  hand  was  last  applied  ; the  napkins,  also,  round  the 
hips  and  on  the  vulva,  must  be  again  inspected,  that  we  may  assure  ourselves 
no  external  haemorrhage  is  going  on.  If,  upon  this  examination,  we  find 
that  the  uterus  is  still  as  small,  and  almost  as  hard  as  a foetal  head — if  the 
linen  be  but  little  soiled — if  not  more  than  two  or  three  coagula,  the  size 
of  a nut,  have  passed — we  need  be  under  no  alarm  with  regard  to  the 
state  of  the  patient ; so  far  as  haemorrhage  is  concerned,  she  is  safe,  most 
probably,  for  that  labour ; at  any  rate  for  the  present  moment.  If,  on  the 
contrary,  we  observe  a considerable  discharge  of  blood  upon  the  bed,  if 
the  uterus  be  large,  soft,  and  flaccid ; or  if,  on  pressure  being  employed,  a 
coagulum  escapes,  or  a quantity  of  fluid  blood  passes,  with  a gurgling 
noise,  she  is  then  flooding ; she  must  not  be  left,  but  will  require  careful 
superintendence,  probably  for  many  hours. 

Presuming,  however,  that  the  case  is  of  the  more  common  kind — one  in 
which  the  uterus  is  small  and  contracted,  in  which  there  is  a slight  discharge 
from  the  external  parts, — the  napkins  being  but  partially  soaked, — and  in 
which  the  feelings  are  comparatively  comfortable,  we  may  take  our  leave, 
giving  instructions  to  the  nurse  with  regard  to  her  future  management,  until 
our  next  visit;  and  these  instructions  should  be  clear,- positive,  and  definite; 
for  the  patient’s  welfare  and  comfort  so  much  depend  on  proper  attention 
being  paid  her  during  the  next  few  hours,  that  nothing  should  be  left  to  the 
caprice  or  prejudice  of  a nurse.  The  first  injunction  to  be  given  is  as  to 
the  length  of  time  she  should  be  allowed  to  remain  quiet  until  her  linen  is 
changed,  and  she  is  removed  from  her  position.  If  there  be  neither 
haemorrhage  nor  faintness,  she  need  not  lie  longer  than  an  hour  or  an  hour 
and  a half  from  the  time  the  placenta  came  away.  The  next  must  be 
with  regard  to  the  mode  of  removal.  She  must  not  be  allowed  to  get  off 
the  bed,  either  to  sit  or  stand  ; nor  must  she  of  her  own  accord  move  hand 
or  foot  in  the  way  of  exertion ; she  must  have  the  dress  in  which  she  was 

something  should  be  ordered; — not  simply  because  it  is  expected; — not  merely  because  the 
patient  may  consider  herself  neglected  if  it  be  omitted,  and  may  attribute  any  inconvenience 
she  may  afterwards  suffer  to  that  omission ; — but  because  it  tends  to  keep  down  excitement, 
and  to  induce  repose.  The  old-fashioned  spermaceti  draught  used  to  be  a favourite  medicine 
after  labour.  It  was  administered  under  the  idea  that  spermaceti  was  a specific  for  inward 
contusions,  and  that  under  labour  the  neck  and  mouth  of  the  uterus,  and  the  vagina,  were 
necessarily  bruised  by  the  passage  of  the  child.  Both  the  positions,  however,  on  which  this 
practice  was  founded,  are  erroneous ; neither  is  spermaceti  a specific  for  inward  bruises,  nor 
is  it  usual  for  any  inward  bruising  to  take  place  under  labour.  But  spermaceti  forms  an  ele- 
gant draught,  and  is  a harmless  drug,  and  there  exists  no  objection  that  I am  aware  of  to  its 
exhibition. 


145 


natural  labour,  ( After  Treatment . ) 

delivered  taken  off  as  quietly  as  possible;  fresh  linen  placed  on  her  person; 
and  she  must  be  lifted,  with  the  least  possible  assistance  on  her  part,  into 
the  place  previously  prepared  for  her. 

Bandage. — We  must  not  omit  to  give  directions  about  a bandage,  or 
safeguard , as  it  is  usually  called,  in  the  idiom  of  the  puerperal  chamber. 
Most  frequently,  indeed,  the  medical  man’s  attention  is  called  to  the  pro- 
priety of  its  application,  either  by  the  nurse  or  the  patient  herself,  so  that 
it  seldom  becomes  necessary  for  him  to  give  orders  respecting  it : for 
women  have  an  idea  that  the  more  tightly  their  persons  are  braced  after 
delivery,  the  more  likely  are  they  to  preserve  the  symmetry  of  their  form ; 
and  this  is  a point  very  near  their  heart.  There  are  few,  indeed,  who 
are  careless  about  possessing  a good  figure ; and  so  long  as  this  prejudice 
prevails — while  the  female  breast  continues  to  throb  with  its  present  pas- 
sions and  desires — so  long  nothing  will  be  neglected  by  them  to  improve 
those  personal  graces  with  which  nature,  in  her  prodigality,  has  enriched 
them.  Some  practitioners  adapt  the  bandage  themselves,  and  apply  it 
immediately  after  the  placenta  has  been  removed.  I think  it  preferable 
in  common  cases  to  leave  this  duty  to  the  nurse ; and  that  it  should  not 
be  put  on  until  the  body-linen  of  the  patient  is  shifted.  Because,  in  the 
first  place,  it  appears  to  me  most  desirable  that  perfect  quietness  should  be 
preserved  until  the  first  changes  in  the  uterus  consequent  upon  labour  are 
effected,  that  no  disturbance  may  interrupt  their  progress ; and  in  the 
second,  I cannot  help  thinking  that  there  is  something  highly  indelicate  in 
its  being  applied  by  a man, — much  more  so,  indeed,  than  any  of  the  duties 
we  are  ordinarily  called  upon  to  perform  under  natural  labour.  It  is  of 
most  service  when  next  the  skin ; it  must  be  sufficiently  broad  to  reach 
from  the  pubes,  almost  to  the  ensiform  cartilage,  and  it  cannot  be  properlv 
adapted  unless  the  abdomen  be  quite  uncovered.  In  addition,  I would 
remark  that  the  nurse  must  know  very  little  of  her  duties,  if  she  cannot 
draw  a properly  contrived  bandage  round  the  person,  and  give  it  the  due 
degree  of  tightness  without  incurring  danger. 

The  principal  object  which  the  bandage  serves  is  to  brace  the  bowels, 
and  give  an  artificial  support,  in  lieu  of  that  which  they  have  lost  through 
the  laxity  of  the  abdominal  muscles : and  to  prevent  the  faintness  frequently 
attendant  on  the  sudden  removal  of  a certain  degree  of  pressure.  It  may 
to  some  extent,  indeed,  stimulate  the  uterus  to  more  perfect  contraction ; 
but  if  that  organ  be  unnaturally  flaccid,  it  would  be  wrong  to  rely  on 
compression  by  a bandage,  to  ensure  its  more  powerful  action,  or  prevent 
its  cavity  being  distended  with  blood ;— in  such  a case,  the  only  safe  means 
of  exerting  sufficient  external  pressure  is  by  the  grasp  of  the  hand  steadily 
and,  for  some  time,  unremittingly,  applied. 

The  interval  that  should  be  allowed  to  elapse  between  the  present  and 
19 


146 


natural  labour,  ( After  Treatment.) 

our  next  visit  must  depend  on  circumstances ; — it  should  certainly  not  be 
deferred  beyond  twenty-four  hours,  but  it  is  much  better  that  it  should  be 
made  within  twelve. 

There  are  many  points  to  which  our  attention  must  be  directed  upon 
our  first  visit.  We  must  learn  whether  our  patient  has  been  much  harassed 
with  pain,  and  what  sleep  has  been  obtained ; for  sleep,  the  grand  restorer 
of  wearied  nature,  is  especially  requisite  after  labour.  It  is  fortunate  if 
we  are  informed  that  she  has  had  two  or  three  refreshing  slumbers.  We 
do  not  expect  uninterrupted  rest,  because  she  will  be  disturbed  by  the 
after-pains ; but  if  she  has  not  suffered  much  from  this  cause  of  annoyance, 
and  has  enjoyed  three  or  four  hours’  sleep  during  the  first  twelve  or  eigh- 
teen hours,  we  consider  it  as  a good  average.  Of  the  nurse  we  require  to 
learn  whether  any  water  has  passed  from  the  bladder,  (for  that  is  a 
matter  of  great  consequence ;)  and  what  sort  of  a discharge  has  issued  from 
the  vagina.  The  sanguineous  discharge  does  not  cease  as  soon  as  the 
placenta  is  expelled,  nor  ought  it  to  disappear  suddenly ; but  a continual 
oozing  of  blood  goes  on  from  the  uterine  vessels,  in  a greater  or  less  quan- 
tity, for  some  time  after  delivery.  In  scientific  language,  this  flow  is 
known  by  the  name  of  the  lochia ; among  women,  in  general,  by  that  of 
discharge;  and  by  the  vulgar  it  is  called  the  cleansings.  For  some  days 
this  discharge  continues  to  possess  all  the  constituent  parts  of  the  blood ; 
but  it  gradually  loses  the  firmer  portions  and  red  globules ; and  before  its 
final  departure  it  becomes  of  a serous  character,  possessing  a greenish 
tint ; it  is  then  known,  in  the  language  of  the  lying-in  room,  by  the  name 
of  the  green  waters , This  change  in  its  character  and  appearance  is  the 
result  of  the  continued  contraction  going  on  in  the  uterus.  At  first,  when 
the  uterine  parietes  are  comparatively  lax ; when  the  vessels  are  of  large 
diameter,  and  their  apertures  perfectly  patulous,  all  the  essentials  of  the 
blood  are  allowed  to  escape  through  them ; and  the  discharge  is  conse- 
quently purely  sanguineous:  but  after  a time,  in  proportion  as  the  uterus 
contracts, — as  the  vessels  are  diminished  in  their  calibre, — as  the  openings 
through  which  the  blood  exudes  become  smaller, — the  fibrin  and  red  glo- 
bules, by' degrees,  are  prevented  escaping,  until  at  last  the  serum  only 
oozes  out,  carrying  with  it  the  smallest  possible  quantity  of  the  colouring 
particles.  On  any  exertion  indeed  being  used,  and  sometimes  merely  on 
the  first  rising  from  the  bed,  the  discharge  may  assume  a more  florid  hue, 
and  be  more  copious  than  it  had  been  for  some  time  past : unless,  how- 
ever, this  be  to  a debilitating  extent,  it  is  not  usually  necessary  to  enjoin 
any  stricter  confinement  in  consequence,  If,  then,  on  our  first  visit,  we 
learn  that  the  bladder  has  acted  freely,  although,  perhaps,  with  some 
trifling  pain;  that  the  discharge  has  been  sufficient  to  have  required  the 
removal  of  four  or  six  napkins, — and  that  a small  coagulum  or  two  has  also 


147 


natural  labour,  {After  Treatment. ) 

passed ; we  may  consider  the  actions  of  the  pelvic  viscera  so  far  to  be 
going  on  in  a healthy  manner.  We  are  not  to  expect  that  any  faeces  will 
have  been  avoided ; it  is  very  rarely  that  the  bowels  act  within  the  first 
twenty-four  hours  after  delivery,  unless  diarrhoea  have  existed  previously 
to  the  accession  of  labour. 

After  information  on  these  points  is  obtained,  we  may  require  to  place 
our  hand  on  the  abdomen,  to  ascertain  whether  the  uterus  is  still  con- 
tracted, and  whether  pressure  upon  it  gives  pain ; and  we  may,  at  the 
same  time,  learn  whether  the  bandage  is  properly  applied.  If  it  has 
shifted  its  position  up  towards  the  bosom,  as  it  frequently  does,  we  must 
desire  the  nurse  again  to.  adapt  it.  We  must,  of  course,  make  our  obser- 
vations on  the  tongue,  pulse,  and  countenance  : from  the  appearance  of  the 
latter,  we  shall  gain  more  information  than  can  be  described.  If  the 
patient  looks  pale,  haggard,  anxious,  and  weary;  if  her  features  are  shrunk, 
something  is  wrong : if,  on  the  contrary,  she  is  placid, — her  countenance 
resuming  its  natural  expression,  even  although  more  than  usually  pallid; 
while  the  pulse  is  seventy  or  eighty,  the  tongue  and  mouth  moist  and  clean, 
there  is  every  indication  of  a favourable  issue  of  the  case. 

It  is  not  right  that  we  should  leave  the  house,  without  taking  some 
notice  of  the  infant.  We  must  learn  whether  it  has  passed  urine  and 
stools ; and  should  the  answer  not  be  satisfactory,  we  must  make  a per- 
sonal examination,  that  we  may  early  detect  any  malformation  which  may 
exist  in  the  rectum  or  external  urinary  organs. 

We  must  also  direct  our  attention  to  the  state  of  the  mothers  bowels. 
It  is  the  custom  in  London  to  give  an  aperient  draught  on  the  morning  of 
the  third  day  after  labour.  Castor  oil,  or  a common  black  draught,  will 
be  found  as  efficacious  as  any  kind  of  purgative ; they  both  generally  ope- 
rate speedily  and  satisfactorily,  without  causing  much  pain.  The  dose 
should  be  repeated  every  four  or  six  hours,  till  the  bowels  act ; for  it  is 
highly  desirable  that  evacuations  should  be  obtained  during  the  course  of 
the  third  day. 

A plan  of  diet  must  be  laid  down  for  some  days  to  come.  Nothing 
should  be  allowed  but  tea,  toast,  or  farinaceous  food,  until  the  bowels  are 
freely  opened ; and  after  the  operation  of  the  laxative,  on  the  same  day,  a 
little  beef-tea,  mutton  or  chicken  broth,  may  be  given.  Such  kind  of 
nourishment  is  all  that  is  required  to  sustain  the  system,  under  any  depres- 
sion the  action  of  the  bowels  may  have  caused. 

On  the  third  day,  the  patient  may  take  for  nourishment  some  solution  of 
animal  matter;  the  next  day,  or  day  after,  nothing  forbidding,  she  may 
add  to  this  a light  pudding;  and  in  a week  she  may  be  allowed  a small 
quantity  of  solid  meat.  Stimulants  of  any  kind,  unless  there  be  an  actual 
necessity  for  them,  never  should  be  permitted  until  about  the  end  of  a fort- 


148  natural  labour,  {After  Treatment.) 

night,  and  then  a glass  of  wine  and  water,  or  mild  malt  liquor,  may  be 
taken. 

The  temperature  of  the  room  must  not  be  overlooked.  Even  in  the 
midst  of  summer,  the  curtains  are  often  found  drawn  close  around  the 
bed,  and  a fire  in  the  chamber ; and  when  the  finger  is  laid  on  the  pulse, 
it  is  observed  to  be  quickened  by  the  application  of  external  heat,  while,  at 
the  same  time,  a profuse  perspiration  bedews  the  skin.  The  curtains 
should  be  undrawn,  that  free  ventilation  may  be  permitted,  and  directions 
should  be  given  that  no  larger  fire  be  kept  than  is  required  for  the  purposes 
of  the  lying-in  room.  It  is  as  well  to  hang  a thermemoter  constantly  in 
the  apartment,  that  the  temperature  may  be  regulated  every  day.  Between 
62°  and  65°  will  be  found  the  most  suitable  warmth,  both  in  winter  and 
summer. 

Till  the  middle  of  the  last  century,  it  used  to  be  the  practice  to  force  a 
woman’s  system  with  spices  and  cordials,  immediately  after  she  was  deli- 
vered ; to  prevent  her  enjoying  a single  breath  of  fresh  air ; to  put  sand- 
bags under  the  chink  of  the  door;  to  nail  the  windows  round  with  list,  and 
take  every  possible  precaution  to  oblige  her  to  breathe  over  and  over  again 
the  same  vitiated  atmosphere.  A more  sure  method  of  exciting  fever 
could  scarcely  be  adopted.  In  more  early  times,  plasters,  fumigations, 
fomentations,  cataplasms,  ointments,  and  oils,  mostly  composed  of  stimu- 
lating or  odoriferous  drugs,  were  applied  to  the  abdomen  and  vulva,  with 
the  view  of  promoting  a free  lochial  discharge  ;*  and  we  are  told  that 
those  women  who  had  the  misfortune  to  be  in  affluent  circumstances, 
were  compelled  to  submit  to  the  infliction  of  a sheep’s,  or,  in  default  of 
that,  a hare’s-skin,  warm  and  reeking  from  the  carcass  of  the  animal 
flayed  alive,  which  was  placed  round  the  abdomen,  to  cherish  and  pro- 
tect them.f  It  is  not  wonderful  that  inflammatory,  typhoid,  miliary,  and 
other  fevers,  were  in  those  days  rife ; we  can  only  be  astonished  that,  in 
any  case,  nature  had  power  to  avert  the  dangers  which  such  an  inter- 
ference with  her  laws,  and  subversion  of  her  intentions,  must  have 
created. 

These  observations,  however,  refer  particularly  to  the  middle  ages  and 

* Mauricean,  vol.  i.  p.  374,  4to.  edit. 

t Guillemeau.  See  also  Chamberlin’s  Midwife’s  Practice,  p.  122.  Chapman,  in  his  Trea- 
tise on  Midwifery,  p.  259,  strongly  recommends  this  to  be  done  after  a hard  labour.  He  states 
that  “ he  has  for  many  years  had  a happy  experience  of  this  method.”  Dionis,  p.  361,  trans- 
lation, tells  us  that  Clement  applied  a fresh  sheep’s-skin  to  the  Dauphiness  of  France,  after 
the  birth  of  her  first  child,  “ but  never  afterwards,  because  it  was  thought  it  did  more  harm 
than  good.”  Ambrose  Pare  (Johnson’s  Translation,  folio,  p.  557)  advises  that  the  after-birth 
while  warm  should  be  laid  to  the  vulva,  especially  in  the  winter ; and  that  in  summer,  the 
skin  of  a wether  recently  killed  should  be  applied  over  the  abdomen  and  loins  for  five  or  six 
hours.  So  that  such  filthy  practices  seem  to  have  been  very  generally  followed. 


149 


natural  labour,  ( After  Treatment.) 

succeeding  years ; for  the  ancients  treated  puerperal  women  as  though 
they  had  suffered  some  violent  and  extensive  accident,  as  we  learn  from 
the  recommendations  inculcated  by  Celsus.*  They  were  confined  for  a 
certain  number  of  days  to  the  sparest  diet,  and  severest  regimen.  Of  the 
two  methods,  that  advised  by  Celsus  must  be  regarded,  on  the  whole,  as 
most  consonant  with  reason ; — nevertheless,  no  general  plan  can  be  uni- 
versally applicable,  but  a deviation  from  it  must  in  some  instances  be 
necessary. 

The  woman  must  be  kept  in  the  recumbent  posture  as  much  as  possible, 
for  at  least  a week.  It  is  better  that  she  should  not  sit  up,  even  to  have 
the  bed  arranged,  for  that  time.  She  may  be  moved  daily  from  one  side 
of  the  bed  to  the  other,  and  lie  on  each  alternately.  In  this  manner  she 
can  have  the  advantage  of  the  change  every  day.  If  a bed,  however, 
heats  her,  or  lying  on  it  is  very  irksome,  she  may  recline  for  an  hour  on 
a sofa,  carefully  preserving  the  horizontal  posture.  The  ninth  after 
delivery  is  looked  upon,  by  women,  as  a critical  day : many  consider 
that,  if  they  have  so  far  escaped  the  dangers  of  the  puerperal  state,  when 
that  day  is  past  they  are  safe  from  all  the  perils  of  their  condition  : and 
some  think  that  however  much  they  may  have  indulged  their  appetites 
before,  and  although  they  may  have  been  up  for  some  hours  for  the  two 
or  three  preceding  days,  on  that  they  are  bound  to  fast  and  keep  their 
bed.  Although  the  prejudice  of  the  ninth  being  a critical  day  is  founded 
on  error,  it  is  as  well  to  favour  it ; because  it  is  highly  desirable  that 
every  woman  should  be  kept  in  a state  of  perfect  rest,  and  should  submit 
to  be  treated  strictly  as  an  invalid — at  any  rate,  until  that  period  of  time 
has  gone  by. 

After  a week,  she  may  get  up,  and  lie  the  principal  part  of  the  day  on 
a sofa.  After  a fortnight  she  may  begin  to  put  her  feet  to  the  ground, 
and  she  way  take  an  occasional  walk  about  the  room:  but  the  liberty 
allowed  in  this  respect  must  depend  very  much  on  the  continuance  of  the 
lochia.  So  long  as  the  discharge  is  flowing  at  all  profusely,  the  necessary 
changes  going  on  within  the  pelvis  are  by  no  means  perfected ; but  if  it 
has  almost  ceased  at  the  end  of  fourteen  or  eighteen  days,  we  may  sup- 
pose that  the  uterus  has  nearly  re-acquired  its  small  unimpregnated  size, 
and  that  the  parts  are  pretty  well  restored  to  their  original  tone. 

We  are  expected,  in  this  country,  to  give  our  attention  both  to  the 
mother  and  her  infant  during  the  whole  puerperal  month;  or  at  least  until 
she  has  quitted  her  chamber : it  is  necessary  that  a visit  should  be  made 
daily,  until  the  end  of  a week  ; after  which  time,  the  attendance  may  be 
regulated  according  to  the  circumstances  of  each  case.  At  every  visit 


* Lib.  vii.cap.  29. 


150 


sue  KLI  NG. 


the  state  of  the  bowels  must  be  particularly  inquired  into,  and  care  must 
be  taken  that  they  act  sufficiently.  They  are  usually  torpid  while  the 
woman  is  inactive,  and  it  is  requisite  to  repeat  the  aperient  draught,  or 
administer  and  enema  occasionally.  The  bandage  should  be  tightened, 
and  the  vulva  sponged  daily  with  warm  water,  to  which  a little  spirit 
may  be  added.  After  three  or  four  weeks,  cold  water  may  be  substi- 
tuted, and  the  parts  may  be  liberally  sluiced  with  it ; especially  if  the 
time  of  year  be  summer. 

Suckling. — It  is  not  generally  that  we  are  asked  the  question  whether 
a woman  should  suckle  her  child  or  not ; or  are  called  upon  to  interfere. 
If  the  patient  be  well,  and  she  does  not  mean  to  suckle,  she  will  not 
consult  her  medical  man  about  it,  because  she  knows  his  advice  will  go 
exactly  contrary  to  her  intentions : but  if  she  be  ill,  and  cannot,  it  is  then 
our  part  to  prevent  her  continuing  her  fruitless  efforts,  and  to  require  that 
a wet  nurse  should  be  procured  for  the  child.*  Some  women  are  averse 
from  suckling,  because  of  the  trouble  and  confinement  it  necessarily 
occasions ; but  others,  on  the  contrary,  regard  it  as  the  most  grateful  and 
pleasing  office  they  can  perform.  No  one  will  deny  that  it  is  the  bounden 
duty  of  every  woman, — provided  she  has  health  and  strength,  and  means, 
— to  nurse  her  own  child,  in  whatever  station  of  life  she  m^y  he  placed. 
She  should  forego  the  pleasures  of  society,  give  up  the  necessity  of 
appearing  in  public,  and  waive  the  etiquette  even  of  a court,  if  those 
pleasures,  or  that  etiquette,  interfere  in  any  material  degree  with  her 
duties  to  her  infant.  I cannot  allow  that  a physician  would  be  honestly 
and  conscientiously  fulfilling  the  trust  reposed  in  him,  who  did  not,  even  in 
the  highest  grade  of  society,  point  out  the  dangers  that  may  spring  from 
this  most  natural  and  engaging  employment  being  abandoned;  and  I 
should  always  think  better  of  that  woman’s  feelings,  both  towards  her 
husband  and  her  infant,  who  gave  it  the  advantage  of  her  own  breast. 

No  doubt  it  is  much  both  to  the  mother’s  and  child’s  happiness,  comfort, 
and  health,  for  the  process  of  suckling  to  go  on.  Every  thinking  person 
will  agree  that  milk,  being  the  nourishment  afforded  by  nature,  is  much 
more  congenial  to  the  child’s  wants  than  any  extraneous  food;  that  it  is 
most  likely  to  afford  suitable  sustenance,  and  preserve  the  system  in  a 
healthy  state.  Nor  is  the  function  of  lactation,  indeed,  less  beneficial  to 


* The  time  when  the  infant  should  be  first  put  to  the  mother’s  breast  must  vary  considera- 
bly in  different  cases.  If  there  has  been  a copious  secretion  from  the  mammary  glands 
during  the  last  few  weeks  of  gestation,  as  sometimes  happens,  the  child  should  be  applied 
early,  as  soon  indeed  as  the  woman’s  strength  is  at  all  recruited,  for  it  will  bring  her  great 
relief : but  if  the  breasts  are  flaccid  and  empty,  a longer  time  must  be  allowed  to  elapse. 
Generally  it  is  both  safe  and  advantageous  for  the  child  to  6uck  within  twelve  hours. 


SUCKLING. 


151 


the  mother  than  her  infant,  although  its  benefits  to  her  may  not  be  so 
immediately  apparent:  for,  putting  out  of  the  question  the  more  obvious 
ill  effects  that  flow  from  suppressed  secretion, — such  as  inflammation  of 
the  glands  of  the  breast,  and  consequent  suppuration, — many  less  evident 
evils  arise,  among  which  may  be  enumerated  congestion  of  the  abdominal 
and  pelvic  viscera,  and  undue  determination  to  the  head, — the  consequence 
of  that  blood  which  ought  to  be  drained  away  from  the  general  system  by 
the  breast,  for  the  formation  of  milk,  being  suddenly  thrown  into  other 
channels,  and  upon  other  organs : — so  that,  independently  of  the  strong 
natural  inclination  which  would  prompt  every  woman  to  suckle,  the 
child’s  safety  and  her  own  health  should  also  stimulate  her  to  undertake 
the  gratifying  and  important  office  of  a nurse. 

One  of  the  most  frequent  causes  inducing  a woman  to  decline  giving 
her  child  the  breast,  is  the  existence  of  sore  nipples ; and  it  certainly 
appears  cruel  to  insist  on  a continuance  of  what  produces  so  much  pain. 
But  we  have  means  to  defend  the  tender  organ ; and  we  can  cure  the 
ulceration:  and  this  in  itself  is  seldom  of  sufficient  importance  to  justify 
our  allowing  a mother  to  put  her  child  away. 

Sometimes,  however,  we  find, — especially  among  the  poorer  classes, — 
that  women  will  suckle  longer  than  is  desirable  for  their  own  strength, 
and  for  the  health  of  their  infants,  under  the  belief  that  they  are  not  sus- 
ceptible of  pregnancy  so  long  as  the  least  secretion  of  milk  is  kept  up  by 
the  lacteal  glands.  To  a certain  extent  this  idea  is  correct ; women  are 
undoubtedly  not  so  likely  to  become  pregnant  while  nursing,  as  after  the 
cessation  of  that  function,  provided  they  continue  to  suckle  for  the  period 
only  that  nature  intended : but  if  they  exceed  the  just  limit,  keeping  the 
child  at  the  breast  affords  them  little  or  no  protection.  Thus  among  the 
lower  orders  it  is  not  very  uncommon  to  see  a woman  suckling  her  last 
infant  till  within  three  or  four  months  of  her  next  confinement,  much  to 
the  destruction  of  her  health,  and  the  undermining  of  her  bodily  powers. 
We  mostly  observe,  indeed,  that  the  milk  in  twelve  or  fourteen  months 
after  delivery  decreases  in  quantity,  and  becomes  deteriorated  in  quality ; 
and  the  child  now  evidently  requires  other  nourishment  than  what  the 
breast  affords.  Some  line,  then,  must  be  drawn  at  which  the  infant  should 
be  weaned ; and  perhaps,  as  a general  principle,  twelve  or  thirteen  months 
will  be  found  the  most  fitting  time ; for  then  its  digestive  apparatus  will  easily 
assimilate  both  farinaceous  nourishment,  and  different  preparations  of 
animal  matter. 


I 


152 


IRREGUL ARITIES  OF 


IRREGULARITIES  OF  HEAD  PRESENTATION. 


Notwithstanding  that  according  to  the  arrangement  which  I have 
chosen,  all  varieties  of  head  presentation  are  considered  natural ; still,  as 
some  are  of  infrequent  occurrence,  they  may  be  regarded  as  irregularities; 
and  under  that  term  I shall  proceed  to  describe  them. 

Vertex  presentation,  with  the  face  behind  either  groin. — When  the 
foetal  cranium  enters  the  pelvis  with  the  face  situated  behind  either  of  the 
groins,  Plate  XXIII.  fig.  77,  and  PI.  XXIV.  fig.  78,  it  must  be  evident,  as 
I have  before  remarked,  that  the  head  is  by  no  means  so  well  adapted  to 
the  cavity,  as  when  the  face  is  directed  to  the  ilium,  Plate  XXII.  figs.  73, 
74,  or  looks  diagonally  backwards  to  one  of  the  sacro-iliac  symphyses, 
Plate  XXIII.  figs.  75,  76 ; and  this  want  of  accommodation  often  induces  a 
lingering  labour,  and  sometimes  obliges  us  to  have  recourse  to  instru- 
mental aid. 

But  although  a tedious  case  may  be  anticipated  under  this  malposition ; 
although  the  sufferings  may  be  greater,  and  the  time  of  duration  more 
protracted  than  is  usual ; — the  mere  irregularity  of  situation  is  not  of  itself 
sufficient  to  warrant  us  in  terminating  the  case  by  artificial  means.  We 
are  not  to  interfere  instrumentally  because  the  face  is  placed  anteriorly ; 
but  we  must  wait  till  some  circumstances  appear  which  call  imperatively 
for  relief  and  assistance.  It  matters  not  whether  the  face  is  looking  back- 
wards or  forwards, — to  one  side  or  the  other, — provided  such  symptoms 
arise  as  indicate  danger,  it  is  our  duty  not  to  allow  them  to  become  aggra- 
vated, but  to  deliver  the  patient  by  those  means  which  are  least  likely  to 
do  injury.* 

* The  mechanism  of  the  head's  passage  under  this  presentation  will  be  found  at  page  108. 
When  the  face  turns  forwards  on  the  expulsion  of  the  head,  the  body  passes  with  the  back  of 
the  shoulders  sweeping  the  hollow  of  the  sacrum,  Plate  XXVIII.  fig.  87.  They  then  turn  a 
little  sideways ; and  the  centre  of  the  abdomen  appears  under  one  of  the  rami  of  the  pubes, 
instead  of  being  directed  backwards  as  in  the  more  ordinary  cases.  Professor  Naegelb  is  of 
opinion  that,  when  the  vertex  presents,  the  anterior  fontanelle  looks  towards  the  left  groin 
much  oflener  than  is  generally  supposed  ; indeed,  that  this  is  by  far  the  most  frequent  posi- 
tion, next  to  that  in  which  it  is  directed  to  the  right  sacro-iliac  symphysis:  and  he  says  he  is 
thoroughly  convinced,  when  the  face  looks  diagonally  forwards  at  the  commencement  of  labour, 
that  not  the  occiput,  but  the  face,  is  generally  turned  into  the  hollow  of  the  sacrum ; and  that 
“ this  change  in  position  requires  no  peculiarly  favourable  circumstances ; but  that  these  species 
of  labours  can  be  completed  by  the  natural  powers  under  the  most  usual  proportions,  in  the 
same  time,  with  the  same  expense  of  strength,  and  without  greater  difficulty,  than  when  the 
head  takes  the  most  common  position.”  He  states,  also,  that  out  of  ninety-six  cases  in  which 


#r. 


Ti.xs.vm. 


m 


* 


■:V 


S' 


■■•■  * ' 


. 

■■  ' - i ' - - 


' ,:  *•  ' 


• * ■ ^ 


LI'BRAHY 
Of  THt* 

UNIVERSITY-  OF  ILUNOJ& 


* 


* 

. ♦ 


- V ^ - 


HEAD  PRESENTATION. 


153 


Mode  of  detection.— It  is  not  very  probable  that  this  malposition  will  be 
distinguished  before  the  membranes  break ; because,  as  the  vertex  pre- 
sents, the  posterior  fontanelle  will  first  offer  itself  to  the  finger,  and  it  will 
be  difficult  to  detect  the  course  which  the  different  sutures  take  thus  early 
in  the  labour.  Besides  which,  I have  already  advised  when  we  have  posi- 
tively satisfied  ourselves  the  head  is  the  presenting  part,  that  we  should 
not  endeavour  to  gain  farther  information  respecting  its  precise  position 
while  the  membranous  cyst  remains  entire;  partly  because  of  the  difficulty 
of  doing  so,  but  principally  because  of  the  danger  of  inadvertently  evacu- 
ating the  liquor  amnii  prematurely.  After  the  second  stage,  however,  has 
commenced,  when  the  expulsive  pains  are  well  established,  we  shall  pro- 
bably find  that  the  head  does  not  descend  with  its  usual  ease  and  regu- 
larity; and  on  making  as  accurate  an  examination  as  we  can,  to  ascer- 
tain the  cause  of  the  delay,  we  shall  detect  the  posterior  fontanelle  at  the 
back  part  of  the  pelvis,  against  one  or  other  of  the  sacro-iliac  junctions, 
and  we  shall  be  able  to  trace  the  sagittal  suture  running  upwards  and  for- 
wards, to  terminate  in  the  large  diamond-shaped,  open  space — the  anterior 
fontanelle — situated  behind  the  opposite  groin,  as  would  be  the  case  in 
Plate  XXIII.  fig.  77,  and  PI.  XXIV.  fig.  78. 

Being  assured  that  the  head  occupies  this  situation,  I would  strongly 
enforce  the  recommendation  not  to  interfere  early  in  the  labour,  but  to 
wait  in  the  hope  and  expectation,  either  that  it  will  be  expelled  in  the 
manner  described  at  page  108 ; or  that  the  face  will  be  gradually  turned 
backwards  into  the  hollow  of  the  sacrum,  and  eventually  make  its  exit, 
sweeping  the  perineum.  Presuming,  however,  that  after  a number  of  tole- 
rably strong  expulsive  pains,  no  advance  takes  place  in  the  situation  of 
the  head,  it  will  then  be  proper  to  embrace  the  cranium  between  the  first 
three  fingers  and  the  thumb  of  one  or  other  hand,  and  to  give  the  face  an 
inclination  to  the  right  or  left  ilium,  according  as  its  original  direction  was 
to  the  right  or  left  groin : and  this  attempt  must  be  made  in  the  absence  of 
uterine  contraction,  and  before  the  head  has  become  locked  in  the  pelvic 
cavity  ; for  if  it  be  delayed  till  a state  of  impaction  has  occurred,  the  mal- 
position cannot  be  remedied  by  the  power  of  the  hand  alone,  and  instru- 


the  face  presented  towards  the  left  groin,  (which  he  observed  with  particular  care,  and  de- 
scribed in  his  note  book,)  in  three  instances  only  the  head  cleared  the  passages  with  the  face 
directed  anteriorly ; and  in  all  these  three  cases  there  were  some  peculiarities  in  the  structure 
of  the  head  or  of  the  pelvis,  to  which  he  seems  to  attribute  the  forward  inclination  of  the 
face. — (Rigby’s  translation,  page  45.)  I am  willing  to  acknowledge  that  in  many  instances 
the  head  will  follow  this  three-quarter  turn  of  the  half  pelvis,  when  the  face  has  originally 
presented  obliquely  forwards;  but  according  to  the  commonly  received  opinions,  and  also  to 
my  experience,  Naegele  has  overrated  the  frequency,  as  well  of  this  presentation  as  of  the 
mode  of  the  head’s  passage,  when  it  does  occur. 

20 


154 


IRREGULARITIES  OF 


ments  will  most  likely  be  required  in  order  to  finish  the  delivery.  In 
making  this  change  in  the  position  of  the  head,  it  would  not  be  right  to 
turn  the  face  at  once  into  the  hollow  of  the  sacrum,  even  if  that  could  be 
accomplished  ; because  the  probability  is,  that  the  child’s  body,  being  held 
tight  within  the  contracted  uterus,  would  not  follow  the  sweep  which  the 
head  describes ; and  we  should  incur  great  danger  of  injuring  the  neck. 
All  that  we  are  required  to  do,  is  to  incline  the  face  to  one  of  the  ilia,  and 
leave  the  rest  of  the  process  to  nature. 

Face  directed  to  the  'promontory  of  the  sacrum , or  the  symphysis  pubis. — 
It  is  very  rarely  that  the  head  offers  itself,  at  the  commencement  of  labour, 
above  the  brim  of  the  pelvis,  with  the  brow  directed  either  against  the  pro- 
montory of  the  sacrum,  Plate  XXIV.  fig.  79,  or  the  symphysis  pubis,  Plate 
XXIV.  fig.  80  ; so  rarely,  indeed,  that  some  practitioners  of  great  respecta- 
bility have  denied  the  possibility  pf  such  an  occurrence.*  From  my  own 
observation,  however,  I am  perfectly  satisfied  that  both  these  presentations 
occasionally  do  take  place.  Under  this  position  the  head  is  placed  with 
its  longest  diameter  in  the  direction  of  the  shortest  diameter  of  the  pelvic 
brim ; and  if  the  head  and  the  pelvis  be  of  average  dimensions,  it  is  impos- 
sible for  the  head  to  occupy  the  cavity,  unless  a change  in  situation  either 
occur  spontaneously,  or  be  effected  artificially. 

Diagnosis. — In  this  case  the  vertex  is  observed  to  lie  quite  above  the 
brim  of  the  pelvis,  almost  out  of  the  reach  of  the  finger  as  introduced  in  a 
common  examination.  But  although,  from  the  difficulty  in  feeling  the 
presenting  part,  suspicion  may  be  excited  that  the  position  is  irregular,  the 
peculiar  nature  of  that  irregularity  will  probably  not  be  determined  until 
after  the  membranous  cyst  has  given  away.  On  the  sceond  stage  of 
labour,  however,  having  commenced, — following  the  general  direction 
before  laid  down, — it  is  right  that  an  accurate  examination  of  the  head, 
and  of  its  bearings  in  relation  to  the  pelvis,  be  made,  and  we  shall  find 
the  sagittal  suture  running  from  before  directly  backwards,  and  not 
laterally  or  diagonally.  We  may  then  be  assured  that  the  face  is  looking 
either  towards  the  promontory  of  the  sacrum  or  symphysis  pubis,  and 
positive  knowledge  on  that  point  will  be  afforded  by  the  situation  of  the 
anterior  fontanelle.  In  relation  as  this  fontanelle  is  directed  backwards 
or  forwards,  so  will  the  face  be  situated. 

I have  no  doubt  that  this  malposition  is  in  many  instances  rectified  by 
nature  herself ; that  (the  force  of  the  uterine  contractions  being  resisted, 
by  the  approximation  of  the  pelvic  bones  in  their  conjugate  diameter, 
which  do  not  afford  due  and  proportionate  space  for  the  descent  of  the 
head  thus  placed)  the  mechanical  impediment  offered  occasions  a turn, 


* Sec  p.  108. 


HEAD  PRESENTATION. 


155 


with  the  face  to  one  or  other  side,  on  the  same  principles  that  regulate  the 
turn  which  is  observed  to  occur  in  all  natural  cases,  just  before  the  head 
escapes  externally.  There  is  no  more  difficulty  in  believing  that  such  a 
change  of  position  is  likely  to  happen  at  the  upper  than  at  the  lower  pelvic 
aperture. 

Being  satisfied,  then,  of  the  situation  of  the  head  after  the  membranes 
have  broken,  having  watched  the  effect  of  two  or  three  pains,  and  ob- 
serving that  it  evinces  no  disposition  to  accommodate  itself  to  the  dimen- 
sions of  the  pelvic  brim,  it  is  proper, — lest  the  woman  become  worn  out 
by  inefficient  struggles,  and  lest  the  cranium  become  wedged  in  this  un- 
fortunate position, — to  follow  nature’s  dictates,  and  incline  the  face  late- 
rally. This  alteration  in  situation  it  would  not  be  difficult  to  effect,  by 
grasping  the  head  between  the  first  three  fingers  and  thumb  introduced 
into  the  vagina,  provided  the  os  uteri  were  well  dilated,  the  vagina  and 
perineum  sufficiently  relaxed,  and  the  head  remained  above  the  brim,  per- 
fectly moveable,  free,  and  unimpacted.  On  this  slight  alteration  being 
made,  the  head  will  enter  the  pelvis,  all  the  difficulty  will  be  over,  and  the 
case  will  be  reduced  to  one  of  the  most  ordinary  character.  If,  however, 
we  cannot  accomplish  this  object,  let  us  then  be  guided  by  the  general 
rule — to  which  there  is  no  exception— that  of  waiting  till  either  the  lapse 
of  time,  or  symptoms  of  danger,  require  instrumental  interference. 

Brow  Presentation. — Other  parts  of  the  head  besides  the  vertex  may 
present.  The  anterior  fontanelle,  or  brow,  may  be  the  depending  part ; 
and  under  this  presentation  the  face  may  offer  itself  at  the  pelvic  brim, 
looking  to  one  ilium  or  the  other — obliquely  backwards  to  either  sacro- 
iliac synchondrosis — obliquely  forwards  to  either  of  the  groins — directly 
forwards  to  the  symphysis  pubis — or  directly  backwards  towards  the  pro- 
montory of  the  sacrum ; in  the  same  manner,  indeed,  so  far  as  regards  the 
points  of  the  pelvic  parietes,  as  though  the  vertex  presented. 

Under  either  of  these  malpositions  the  head  is  still  less  adapted  to  the 
passage  than  when  the  vertex  presents  with  the  face  forwards,  since  much 
greater  space  is  required  for  its  transmission.  It  has  been  shown  in 
Plate  V.  fig.  19,  that  the  same  cranium,  when  the  brow  or  face  is  directed 
first,  requires  a space  of  nearly  an  inch  more  in  the  longest  diameter,  than 
when  the  vertex  is  protruded. 

Brow  'presentation ; the  face  looking  diagonally  backwards. — In  all  cases 
where  the  anterior  fontanelle  offers  itself  originally,  there  is  a natural  in- 
clination for  the  case  to  be  converted  into  a perfect  face  presentation ; and 
this  is  owing  to  the  fibres  of  the  fundus  uteri  exerting  themselves  strongly 
upon  the  foetal  body ; under  which  action  the  shoulders  are  pressed  down- 


156 


IRREGULARITIES  OF 


wards,  the  chin  is  gradually  separated  more  and  more  from  the  chest, 
and  the  head  is  expelled  in  the  manner  hereafter  to  be  described.  If  Plate 
XXVIII.  fig.  88,  which  represents  a presentation  of  the  brow,  with  the 
chin  to  the  left  sacro-iliac  synchondrosis,  be  compared  with  Plate  XXIX. 
fig.  89,  in  which  is  depicted  a face  case  with  the  chin  to  the  left  ilium,  it 
will  be  easily  seen  how  the  power  of  the  uterine  contractions  tends  to  con- 
vert a brow  into  a complete  face  presentation. 

It  is  very  probable  that  the  presentation  of  the  anterior  fontanelle  may 
be  detected  before  the  membranes  rupture,  because  of  the  large  space  it 
offers  to  the  finger:  but  even  should  this  information  be  obtained  thus  early, 
little  can  be  done  towards  rectifying  the  position  until  the  liquor  amnii  is 
spontaneously  evacuated;  since,  under  any  attempts  we  might  use,  we  should 
almost  unavoidably  destroy  the  integrity  of  the  membranous  cyst,  which 
it  is  of  such  essential  importance  to  preserve  whole.  It  is  necessary  that 
the  case  should  be  watched  carefully  and  narrowly ; and  that,  on  the  rup- 
ture of  the  bag,  an  accurate  examination  should  be  instituted,  with  the 
view  of  determining  whether  the  face  lie  forward,  backward,  or  laterally. 
In  the  case  now  under  consideration,  the  sagittal  suture,  which  becomes 
our  guide,  is  traced  from  the  anterior  fontanelle  running  obliquely  forwards 
and  upwards  to  one  groin  or  the  other.  There  can  then  exist  no  doubt, 
first,  that  the  anterior  fontanelle  presents ; and,  secondly,  that  the  face  is 
placed  backwards  in  relation  to  the  pelvis. 

Inasmuch  as  a considerably  greater  space  is  required  under  a presenta- 
tion of  the  brow  than  when  the  vertex  depends ; inasmuch  as  there  exists 
such  a disposition  to  convert  the  case  into  a face  presentation ; and  inas- 
much as  the  labour  is  usually  protracted,  and  attended  with  a proportion- 
ably  increased  degree  of  pain ; it  would  naturally  follow  that  we  should 
endeavour  to  place  the  head  in  a more  favourable  position,  by  throwing 
the  chin  more  upon  the  chest,  and  causing  the  vertex  to  descend  ; provided 
this  could  be  accomplished  without  incurring  danger,  without  any  aggra- 
vation of  suffering,  and  without  the  formidable  appearance  of  preparing 
for  an  operation.  This  object  can  frequently  be  gained,  if  the  position  be 
detected  soon  after  the  rupture  of  the  membranes,  and  before  the  head  has 
perfectly  engaged  in  the  pelvic  cavity,  by  a very  simple  and  easy  method ; 
it  only  requires  that  steady  pressure  should  be  made  upon  the  brow  with 
the  extremity  of  the  finger  during  the  urgency  of  pain,  so  that  the  fore- 
head may  be  arrested  at  the  spot  to  which  it  has  attained,  and  the  powers 
of  the  uterus  be  expended  upon  the  back  part  of  the  head.  It  is  then 
usually  observed  that  the  head  is  bent  forward  on  the  neck,  as  on  a hinge; 
the  vertex  comes  down,  the  brow  remains  stationary ; and  thus  the  case 
may  be  made  one  of  the  most  simple,  natural,  and  easy.  We  can  only 


P3 . XXIX. 


S i/icZair'^,Xrith 


librarV  s . ' 
!)-  THE«#v 
UNIVERSITY  OF  IIUKOIC 


>W  : 


•**-  . 


* /<* 


4 


♦ 


HEAD  PRESENTATION. 


157 


succeed,  however,  in  this  endeavour  during  the  paroxysm  of  pain : we  are 
not  to  expect  that  we  shall  be  able  to  push  the  anterior  fontanelle  up  above 
the  brim;  our  only  intention  should  be  to  prevent  it  passing  down  farther, 
and  to  give  an  opportunity  for  the  back  part  of  the  head  to  occupy  the 
pelvis  more  completely.  This  counter-pressure,  nevertheless,  must  be 
made  with  caution,  tenderness,  and  judgment. 

Brow  presentation,  with  the  face  forwards . — The  anterior  fontanelle 
may  present  with  the  face  looking  forwards  to  one  or  other  groin ; and 
this  position  is  even  more  unfavourable  than  either  of  those  just  described ; 
because  not  only  is  that  part  of  the  head  presenting,  which  in  itself 
requires  a considerably  increased  space,  but  it  is  placed  in  a most  awk- 
ward situation  as  regards  the  pelvis.  There  is  the  double  disadvantage 
of  a brow  presentation,  and  the  face  being  directed  forwards.  There  can 
be  but  little  difficulty  in  detecting  this  position,  at  any  rate,  after,  or  even 
previously  to,  the  rupture  of  the  membranes : the  anterior  fontanelle  is 
easily  discriminated,  and  the  sagittal  suture  can  be  traced  running 
obliquely  backwards  and  upwards,  until  it  terminates  at  the  superior  angle 
of  the  occipital  bone,  in  the  direction  of  one  of  the  sacro-iliac  symphyses. 

The  same  remarks  just  made  respecting  the  propriety  and  necessity  of 
giving  a new  inclination  to  the  head,  apply  with  equal  truth,  and  even 
more  force,  to  the  variety  now  under  contemplation.  There  is  the  same 
chance  of  the  case  being  converted  into  a face  presentation, — the  same 
likelihood  of  a protracted  termination ; and  we  possess  almost  an  equally 
easy  and  effectual  method  of  rectifying  the  unfortunate  position.  Coun- 
ter-pressure, during  the  time  of  pain,  will  here  also  avail  us  much;  not, 
however,  directed  on  the  centre  of  the  brow,  but  on  one  side,  just  above  the 
temple.  We  may  often  succeed  in  preventing  the  chin  passing  down- 
wards, in  making  the  vertex  the  most  depending  part,  and  in  throwing 
the  face  a little  backwards.  If  we  can  cause  the  head  to  move  in  the 
slightest  degree  so  as  to  direct  the  forehead  opposite  the  iliac  fossa,  we 
shall  find  that  nature  will  eventually  turn  it  with  the  face  into  the  hollow 
of  the  sacrum.  Should  these  attempts,  however,  not  prove  successful, 
the  head  may  be  embraced  between  three  fingers  and  a thumb,  and  a 
rotatory  inclination  given  to  it : the  proper  change  can  thus  generally 
be  effected,  unless  indeed  some  time  has  elapsed  since  the  membranes 
broke. 

The  presentation  of  the  brow  with  the  face  directed  towards  the  promon- 
tory  of  the  sacrum  or  symphysis  pubis,  is  even  more  unusual  than  the  same 
direction  of  the  face,  the  vertex  presenting ; there  will  be  equal  or  even 
more  difficulty  in  its  passage  through  the  brim ; the  same  means  must  be 
taken  to  detect  its  situation,  and  the  same  attempts  used  to  place  it’  in  a 
more  favourable  one. 


]58 


IRREGULARITIES  OF 


Face  Presentation. — I am  inclined  to  think  that  most  of  the  face  pre- 
sentations which  we  meet  with  in  practice  were  originally  brow  presen- 
tations, and  have  been  changed  by  the  action  of  the  uterus  in  the  way  I 
have  already  specified : however,  there  is  no  question  that  the  face  some- 
times offers  itself  even  at  the  very  onset  of  labour.  Various  are  the 
positions  in  which  a foetus,  when  the  face  presents,  may  be  placed ; but 
this  is  the  most  common.  The  crown  of  the  head  is  directed  to  one 
ilium ; the  chest  towards  the  other,  and  a shoulder  towards  the  sacrum 
and  pubes  respectively.  Plate  XXIX.  fig.  89.  As  the  case  progresses,  the  face 
descends  down  into  the  pelvis,  until  the  summit  of  the  head  impinges  on 
one  ischium ; and  the  chin  on  the  other.  The  direction  of  the  head  is 
then  totally  altered ; the  chin  appears  under  the  arch  of  the  pubes,  and 
the  occiput  sweeps  the  perineum.  Plate  XXIX.  fig.  90.  This  change,  I 
believe,  always  takes  place ; at  least  I never  knew  an  instance  of  face 
presentation,  in  which  the  head  was  expelled  with  the  upper  and  back 
part  emerging  from  under  the  pubic  arch.  This  case  requires  even  more 
room  than  any  yet  discussed ; and  if  it  be  a first  child,  it  is  generally 
attended  with  great  difficulty  and  distress  : but  if  the  parts  be  well  relaxed 
— if  the  pelvis  be  good,  and  the  pains  strong — as  a general  principle,  face 
presentations  will  be  terminated  with  little  or  no  assistance. 

Mode  of  detection. — It  is  not  very  difficult  to  detect  a face  presentation, 
even  before  the  membranes  break ; or  rather  it  is  easy  to  determine  that 
no  part  of  the  cranium,  properly  so  called,  presents  ; for  the  face  is  readily 
distinguished  from  the  harder  parts  of  the  head.  On  making  an  exami- 
nation, an  irregular  soft  body  meets  the  finger,  which  indeed,  unless  we 
are  careful  in  our  inquiry,  we  may  possibly  mistake  for  other  parts  of  the 
child.  The  face  has  not  unfrequently  been  confounded  with  the  breech — 
of  which  I have  known  more  than  one  instance ; the  cheeks  have  been 
taken  for  the  nates,  and  the  mouth  for  the  anus.  The  prominence  and 
regularity  of  the  features  will  necessarily  be  our  discriminating  marks. 
Thus  we  may  feel  the  nose  about  the  centre;  the  two  eyes  above;  the 
chin  below,  and  the  mouth,  differing  from  the  anus  in  shape,  size,  and  in 
possessing  lips ; — the  gums  and  the  tongue  can  often  be  felt  also  after  the 
liquor  amnii  is  discharged ; and  then  doubt  can  exist  no  longer.  Besides 
these  sufficiently  striking  features  which  indicate  the  face,  the  breech 
possesses  certain  distinctive  marks  of  its  own,  to  be  hereafter  particularly 
noted.  If  we  are  satisfied  with  simply  placing  our  finger  against  the  puffy 
cheek,  we  are  very  likely  to  fall  into  error ; but  we  are  not  to  form  an 
opinion  by  one  part  alone — we  must  take  all  the  points  that  we  can 
reach  as  diagnostic  marks. 

It  becomes  a most  important  question,  whether  under  a face  presenta- 


HEAD  PRESENTATION. 


159 


tion  any  means  should  be  adopted  to  place  the  child  in  a more  favourable 
position.  So  difficult,  and  almost  impossible,  was  the  transmission  of  the 
head  under  this  presentation  (as  well  as  some  other  of  these  irregularities) 
at  one  time  thought,*  that  it  was  recommended  that  the  hand  should  be 
introduced  into  the  uterus — that  the  feet  should  be  laid  hold  of,  and  that 
the  child  should  be  delivered  by  turning.  This  operation,  performed 
under  the  most  favourable  circumstances,  is  always  attended  with  great 
pain,  and  frequently  with  great  danger — danger  both  to  the  mother 
and  the  child ; — to  the  mother,  from  the  chance  of  injury  to  which  her 
structures  (particularly  the  uterus)  are  exposed — to  the  child,  in  conse- 
quence of  the  pressure  which  the  funis  umbilicalis  must  more  or  less 
experience,  when  the  head  is  passing  through  the  pelvic  cavity.  All 
these  circumstances,  then,  being  taken  into  consideration,  the  practice  of 
changing  the  position  of  the  child  under  a face  impression,  by  turning , is 
now  almost  entirely  exploded ; and  we  rather  lea  Ve  the  case  to  nature,  so 
long  as  we  can  safely  trust  her,  than  subject  the  woman  and  the  infant  to 
such  dangers. 

But  suppose,  on  watching  the  case,  we  find  no  advantage  gained — no 
alteration  in  the  position  of  the  head — no  advance  from  hour  to  hour — 
what  then  is  to  be  done  ? We  must  here  also  act  upon  the  same  unerring 
principles  before  laid  down,  wait  till  symptoms  require  our  interference, 
and  then  use  that  instrument  which  seems  most  applicable  to  the  emer- 
gency. For  it  is  impossible,  by  any  counter  pressure,  to  make  a benefi- 
cial change  in  the  situation  of  the  head  under  a face  presentation.  We 
cannot  cause  the  head  to  turn  upon  the  neck,  so  as  to  approximate  the 
chin  to  the  chest,  by  pressure  applied  by  the  finger ; nor  can  we,  indeed, 
succeed  in  producing  the  same  alteration  by  the  introduction  of  the  hand 
over  the  vertex,  the  adaptation  of  the  points  of  the  fingers  to  the  occiput, 
and  the  application  of  gentle  traction:  as  some  have  recommended.f 
The  vectis,  then — provided  any  instrument  be  required — will  be  found 
the  most  appropriate.  Face  and  ear  presentations,  indeed,  appear  to  me 
the  only  cases  in  which  the  forceps  does  not  possess  an  absolute  supe- 
riority over  the  vectis. 

The  features  of  a child  born  under  a face  presentation  are  generally 
much  swollen,  turgid,  and  livid.  We  must  be  prepared,  therefore,  to 
expect  some  disfigurement ; which,  however,  will  generally  disappear  in  a 
day  or  two. 


* See  Dewees’  Mid.  par.  654. 

t Baudelocque,  par.  1337,  advises  this  method  of  rectifying  the  position,  before  the  head 
has  engaged  in  the  pelvic  aperture.  Sec  also  par.  1870. 


160 


IRRE  GULARITES  OF 


Ear  Presentation. — Ear  presentations  are  by  far  the  most  rare  of  any 
of  these  irregular  positions  of  the  head.  Either  side  of  the  head  may  pre- 
sent ; the  face  may  look  to  one  ilium  or  the  other,  or  to  the  pubes  or  the 
sacrum. 

As  illustrative  of  the  mechanism  of  ear  presentation,  I will  suppose  a 
case  in  which  the  face  is  looking  backwards ; in  which  the  summit  of 
the  head  is  directed  to  the  right  ilium,  and  the  left  shoulder  impinges  on 
the  left  ilium  ; and  in  which  the  ear  meets  the  finger,  immediately  on 
being  passed  up  to  the  pelvic  brim.  Plate  XXX.  fig.  91.  In  this  posi- 
tion, provided  the  head  clears  the  brim,  it  is  usually  propelled  into  the 
pelvis  in  proportion  as  the  trunk  of  the  child  advances,  until  it  comes  to 
press  low  down  upon  the  outlet ; but  in  consequence  of  its  being  doubled 
sideways  on  the  shoulder,  the  space  required  for  its  exit  thus  is  more  than 
the  inferior  pelvic  aperture  affords,  and  before  it  can  escape  it  must  take 
a fresh  direction : a change  in  situation,  therefore,  is  effected ; — not, 
indeed,  a semi-rotatory  turn,  such  as  the  head  describes  under  the  pre- 
sentation of  the  vertex,  but  the  summit  of  the  head  passes  downwards, 
moving  on  the  joints  of  the  neck  as  on  a hinge ; the  face  is  by  degrees 
thrown  into  the  hollow  of  the  sacrum ; and  the  occiput  is  turned  up  under 
the  arch  of  the  pubes.  If  the  face  is  looking  forwards  above  the  sym- 
physis pubis,  the  case  will  be  surrounded  by  increased  difficulties ; but, 
upon  the  whole,  the  remarks  just  made  are  generally  applicable  to  all  ear 
presentations. 

Mode  of  detection. — There  can  be  little  difficulty  in  detecting  an  ear, 
or  in  determining  how  the  head  lies,  when  we  touch  it.  There  is  no 
part  of  the  foetal  body  we  are  likely  to  confound  with  the  ear.  We  can 
feel  the  different  parts  of  the  organ  itself,  and  the  bony  head  surrounding 
it.  We  can  feel  the  helix  or  flap,  and  the  tragus  or  sessile  part ; we  know 
that  behind  the  helix  is  situated  the  occiput,  and  anterior  to  the  tragus,  the 
face ; and  these  points  will  immediately  lead  us  to  distinguish  the  true  posi- 
tion of  the  head  as  regards  the  pelvis. 

Having,  then,  detected  the  ear,  and  ascertained  the  situation  of  the 
head,  three  modes  of  proceeding  offer  themselves  for  our  choice.  We 
may  either  turn  the  child  and  extract  it  by  the  feet;  or  we  may  endea- 
vour to  bring  down  the  vertex ; or,  leaving  the  case  for  some  time  to 
nature,  we  may  hope  that  the  head  will  gradually  assume  a more  favour- 
able direction.  Doubtless  there  are  particular  cases  to  which  each  of 
these  means  may  be  applicable;  but,  upon  the  whole,  the  observa- 
tions I have  just  made  regarding  the  management  of  face  presentations 
are  equally  valid  in  this  case.  Turning  is  not  generally  required,  and 
should  not  be  thought  of  after  the  membranes  have  broken ; no  good 


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HEAD  PRESENTATION. 


161 


can  be  effected  by  counter-pressure;  I cannot  see  what  advantage  could 
be  gained  by  the  introduction  of  the  fingers  over  that  side  of  the  head 
which  lies  uppermost,  even  if  they  could  be  passed  up  without  difficulty ; 
and  it  is  certainly  not  necessary  to  interfere  instrumentally,  merely  because 
the  ear  presents.  The  common  principle  must  here  direct  us ; we  must 
wait  patiently,  in  the  hope  that  nature  will  effect  her  object ; and  should 
the  head  remain  stationary  for  some  time,  or  should  constitutional  symp- 
toms of  distress  supervene,  delivery  must  be  effected  instrumentally ; and 
that  may  probably  be  accomplished  by  the  vectis. 


21 


, ‘ X / * 


. ' 


. i*  % 


DIFFICULT  LABOUR. 


The  second  class  of  labours,  difficult  or  laborious,  embraces  two 
orders,  lingering  and  instrumental . 


Order  i. — LINGERING  LABOUR. 

Plates  XXX.,  XXXI.,  XXXII. 

I have  defined  a lingering  labour  to  be  a case  in  which  the  head  presents  ; 
which  occupies  more  than  twenty-four  hours  from  its  commencement  to 
its  termination ; which  is  concluded  without  the  necessity  for  instrumental 
or  manual  interference ; during  the  progress  of  which  no  dangerous  or 
unusual  symptoms  manifest  themselves ; and  in  which  nothing  calling  for 
anxiety  occurs,  except  the  length  of  time  that  elapses  under  its  conti- 
nuance : so  that  it  differs  only  from  a natural  labour  in  respect  of  its 
duration. 

We  sometimes  hear  of  a woman  being  in  uninterrupted  labour  a week, 
ten  days,  a fortnight,  or  even  longer.  Such  an  idea  is  perfectly  absurd  : 
the  powers  of  the  system  could  not  bear  up  against  the  exertion  of  labour 
for  so  protracted  a period.  Besides  which,  the  active  agents  could  not 
support  their  operations  for  so  long  a time : for  the  uterus,  whether  it  is 
muscular  in  structure  or  not,  obeys  the  laws  of  muscular  action  under 
parturition ; its  powers  become  gradually  enfeebled,  under  a continuance 
of  excessive  toil,  and  it  is  at  last  entirely  disabled  through  exhaustion : 
with  the  cessation  of  its  action,  the  process  of  labour  is  also  at  a stand. 
This  is  exactly  analogous  to  what  we  observe  daily  and  hourly  in  the 
truly  muscular  structures : when  fatigued,  they  contract  feebly  and  unwil- 
lingly,  and  when  their  powers  are  exhausted  they  can  exert  themselves 


164 


LINGERING  LABOUR,  ( CciUSeS.) 

no  longer.  Such  cases,  then,  of  reputed  prolonged  parturition,  are  depend- 
ent on  false,  irritable,  spasmodic  pains,  situated  in  some  other  part  of  the 
body ; by  which,  as  we  have  already  learned,  women  are  frequently 
harassed  towards  the  close  of  gestation ; but  which  are  perfectly  uncon- 
nected with,  and  independent  of,  contraction  in  the  uterine  fibres. 

In  estimating  lingering  labours,  we  calculate  from  the  first  commence- 
ment of  true  uterine  action;  but  in  estimating  the  length  of  labour, 
in  reference  to  the  patient’s  strength,  and  its  effects  on  her  system,  we 
principally  take  into  consideration  the  time  that  has  elapsed  since  the 
membranes  broke ; for  it  is  reasonable  to  infer  that  no  great  exertion  has 
been  sustained — consequently  that  little  or  no  exhaustion  has  appeared ; 
and  particularly,  that  scarce  any  injurious  pressure  can  have  taken  place 
on  the  soft  parts  within  the  pelvis,  while  the  membranous  cyst  remained 
entire;  provided  there  be  an  ordinary  quantity  of  liquor  amnii.  Thus, 
when  called  to  a case  of  lingering  labour,  in  considering  the  chance  of 
injury  from  its  duration,  our  mind  should  be  directed,  not  so  much  to 
the  interval  which  has  elapsed  since  the  first  accession  of  uterine  pains, 
as  to  the  time  at  which  the  membranes  ruptured ; and  that  should  be  looked 
upon  as  the  period  when  it  was  possible  for  dangerous  pressure  to  have 
commenced* 

Causes. — Many  and  various  are  the  causes  which  may  produce  a lin- 
gering labour.  They  may  be  arranged  under  two  distinct  heads — those 
which  are  referable  to  the  mother,  and  those  in  which  the  ovum  is  at  fault. 

The  causes  referable  to  the  mother  are — 

First,  the  want  of  sufficient  power,  or  the  absence  of  sufficient  energy, 
in  the  uterus  itself ; 

Secondly , the  wTant  of  sufficient  room  in  the  bony  pelvis,  to  admit  the 
ready  passage  of  the  foetus ; 

Thirdly , the  presence  of  one  or  more  tumours  in  the  pelvic  cavity  ; 

Fourthly , rigidity  of  the  os  uteri,  vagina,  and  perineum — one  of  these 
organs  being  affected  singly ; or  a combined  rigidity  of  the  whole  tending 
to  retard  the  progress  ; 

Fifthly,  a cicatrix,  or  membranous  impediment,  existing  in  the  vagina ; 
and, 

Sixthly,  obliquity  of  the  os  uteri. 

Those  causes  of  lingering  labour  referable  to  the  ovum  are  said  to 
be — 

First,  preternatural  toughness  of  the  membranes ; 

Secondly,  the  head  being  larger  than  common,  from  natural  healthy 
formation,  deformity,  or  disease ; 

Thirdly,  the  head  being  too  strongly  ossified,  though  not  of  larger  di- 
mensions than  ordinary ; 


LINGERING  LABOUR,  ( Causes.) 


165 


Fourthly , malposition  of  the  head ; 

Fifthly,  ascites  or  tympanites  of  the  foetal  abdomen  ; 

Sixthly,  the  umbilical  cord  being  unnaturally  short,  or  being  twisted 
around  the  body  or  limbs  of  the  foetus ; 

Seventhly,  unusual  bulk  of  the  trunk  or  limbs;  and, 

Eighthly,  monstrosity. 

Some  of  these  causes  in  which  the  child  is  at  fault,  exert  a great  influ- 
ence over  the  duration  of  labour ; while  others  possess  no  power  what- 
ever in  retarding  the  process,  as  far  as  the  head  is  concerned. 


1.  Causes  referable  to  the  Mother. 

1st.  Inefficient  uterine  action . — Labours  rendered  tedious,  or  lingering, 
from  this  cause,  are1  generally  observed  in  constitutions  debilitated  by 
previous  disease,  by  excessive  discharges,  or  some  other  depressing  ac- 
tion. We  often  remark,  also,  that  the  uterus  acts  feebly  when  the  wo- 
man has  previously  borne  a large  family.  In  this  latter  instance,  indeed, 
the  organ  does  not  obey  the  laws  of  muscular  action ; for  the  more  fre- 
quently muscles  are  called  into  powerful  contraction,  the  stronger  they 
become ; — the  uterus,  on  the  contrary,  usually  displays  less  energy  when 
its  peculiar  powers  have  been  often  exerted  in  child-birth. 

This  cause  of  lingering  labour  is  known  by  the  pains  being  weak ; the 
intervals  at  which  they  succeed  each  other,  distant ; the  space  of  time 
during  which  they  continue,  short ; — while,  at  the  same  time  there  pro- 
bably exists  a good  pelvis,  and  a sufficient  degree  of  dilatation  and  laxity 
of  the  passages  to  allow  the  escape  of  the  foetus,  provided  the  propelling 
powers  were  adequate  to  the  end.  In  some  cases,  where  the  delay  is  at- 
tributable to  inefficient  uterine  power,  the  sanguiferous  system  may  also 
be  acting  with  diminished  force ; and  there  are  perhaps  other  symptoms 
present,  indicative  of  general  debility.  It  is  not  likely  that  we  shall  find 
much  difficulty  in  detecting  this  cause  of  lingering  labour. 

Treatment. — Under  these  circumstances,  it  becomes  our  duty  to  endea- 
vour, if  possible,  to  rouse  the  uterine  energies ; by  doing  which  wTe  may 
probably  prevent  the  necessity  for  instrumental  delivery.  This  object  we  can 
sometimes  easily  effect.  The  pains  may  be  augmented  both  in  frequency 
and  strength,  and  may  even  occasionally  be  restored  after  they  have  been  sus- 
pended for  many  hours ; — by  warm  diluent  drinks ; — by  stimulants  taken 
into  the  stomach ; — by  particular  medicines ; — by  friction  and  other  exter- 
nal means ; — and  by  a change  of  posture. 

Of  all  the  methods  employed  for  the  purpose  of  increasing  inefficient, 


166 


LINGERING  LABOUR 


and  restoring  declining  pains,  none  are  more  frequently  had  recourse  to, 
and  none  are  less  injurious,  than  warm  diluents ; they  are  the  simplest  that 
can  be  used,  and  are  often  successful.  It  is  very  common  for  the  nurse, 
when  the  uterine  contractions  are  weak,  short,  irregular  and  distant,  to 
propose  that  some  gruel  or  tea  should  be  given  “ to  bring  back  the  pains.” 
If  such  nourishment  be  grateful  to  the  patient,  if  there  be  no  tendency  to 
vomit,  or  if  she  feels  to  desire  it,  there  can  in  few  cases  be  any  objection 
to  the  exhibition  of  warm  diluents ; and  they  may  be  given  almost  ad  libi- 
tum. To  stimulants,  as  a general  principle,  under  labour,  I am  decidedly 
adverse;  and  consider  it  as  a maxim  never  to  allow  them,  unless  some 
degree  of  faintness  be  present ; or  a languid  state  of  the  general  system 
indicate  their  propriety : because  the  excitement  they  cause  must  be  fol- 
lowed by  a corresponding  depression ; and  they  may  tend  either  to  induce 
fever,  or  hurry  on  exhaustion.  Before  stimulants  are  exhibited,  many 
things  must  be  taken  into  consideration ; such  as  the  state  of  the  pulse  and 
skin ; the  length  of  time  the  labour  has  lasted ; the  strength  of  the  pains ; 
the  degree  of  faintness  the  patient  is  suffering ; and  the  kind  of  discharge. 
Should  the  pulse  be  weak  and  slow,  the  surface  colder  than  natural,  the 
uterine  contractions  powerless,  and  the  system  depressed,  while  at  the  same 
time  there  is  no  blood  flowing  through  the  vagina,  nor  any  symptom  of 
internal  and  concealed  haemorrhage,  stimulants  are  called  for ; and  either 
the  domestic  or  medicated  may  be  allowed. 

Various  specific  medicines  have  been  recommended  at  different  times, 
to  increase  the  parturient  throes,  and  facilitate  the  child’s  birth ; but  I be- 
lieve that  the  whole  of  these  substances,  one  only  excepted,  act  upon  the 
womb  through  the  excitement  induced  in  the  arterial  system.  They  first 
stimulate  the  nervous,  then  the  arterial,  and  through  the  medium  of  those 
systems,  the  uterus.  Almost  the  only  medicine  now  used  as  a uterine 
excitant,  is  the  ergot  of  rye : and  I have  no  hesitation  in  declaring  my  opi- 
nion that  its  action  is  specific,  and  that  the  uterus  is  not  affected  through 
any  disturbance  first  set  up  in  the  arterial  system. 

The  drug  has  been  exhibited  in  various  forms,  chiefly  in  powder,  infu- 
sion, decoction,  and  tincture.  The  first  two  are  in  my  opinion  the  best 
modes.  If  given  in  fine  powder,  about  twenty  grains  is  the  proper  dose ; 
but  I am  myself  generally  in  the  habit  of  exhibiting  it  in  infusion.  Two 
drachms  may  be  infused  in  four  or  six  ounces  of  boiling  water  for  twenty 
minutes ; a fourth  part  of  the  strained  liquor  should  be  given  at  a time, 
and  under  labour  the  dose  may  be  repeated  every  quarter  of  an  hour,  until 
either  its  action  becomes  apparent,  or  the  whole  is  taken ; for  I consider 
it  useless  to  persevere  with  the  medicine,  if  the  quantity  mentioned  pro- 
duces no  effect.  I have  found  that  if  the  infusion  be  allowed  to  stand 
much  longer  than  the  time  I have  specified,  it  acquires  a nauseating  pro- 


FROM  INEFFICIENT  UTERINE  ACTION.  167 

perty  which  greatly  distresses  the  stomach.  Desgranges*  used  only  the 
black  cortical  part,  in  which  he  considered  its  active  principle  to  reside: 
he  gave  it  in  doses  of  four  or  six  grains,  which  he  found  as  efficacious  as 
thirty  grains  of  the  whole  powder.  Villeneuve  administered  it  in  lave- 
ments; and  he  considers  this  the  most  efficacious  means  of  employing  it, 
provided  there  be  present  much  irritability  of  the  stomach. 

I have  given  the  ergot,  in  the  doses  recommended  every  four  or  six  hours, 
for  many  successive  days,  on  several  occasions,  and  never  knew  it  pro- 
duce any  bad  effects  upon  the  mother,  except  occasionally  nausea  and 
vomiting.  Usually  there  is  no  more  influence  perceptible  on  the  general 
system  than  would  be  observed  after  taking  a cup  of  tea ; but  its  effects 
upon  the  uterus  in  labour  are  often  speedy,  powerful,  and  astonishing.  Its 
action  mostly  commences  within  fifteen  or  twenty  minutes  after  its  exhi- 
bition ; and  the  character  of  the  pains  induced  through  its  agency  differs 
materially  from  the  ordinary  throes  of  parturition ; so  that  it  is  possible  in 
many  cases  to  discriminate  them,  as  being  actually  produced  by  the  drug 
itself; — they  are  stronger  and  more  constant  than  the  common  pains  of 
labour.  When  the  ergot  has  obtained  a full  power  over  the  system,  the 
uterus  often  acts  without  any  decided  intermission  for  many  minutes  toge- 
ther ; — there  being  only  a slight  remission  observed — no  interval  of  perfect 
ease.  This  remark  has  been  made  by  Inglebyf  and  many  other  physi- 
cians ; and  I have  had  myself  an  opportunity  of  observing  its  truth  on 
many  occasions. 

As  the  ergot  undoubtedly  possesses  such  a strong  influence  over  the 
uterine  system,  it  is  evident  that,  if  exhibited  improperly,  it  is  likely  to  do 
great  injury. 

There  are  many  cautions,  then,  necessary  to  be  attended  to  in  adopt- 
ing and  employing  it.  Its  exhibition  must  not  bet  hought  of  in  any  case 
where  a disproportion  exists  between  the  head  of  the  child  and  the  pelvic 
cavity  ; we  should  incur  great  danger  of  inducing  contusion,  inflammation, 
and  laceration.  Neither  must  it  be  exhibited  where  there  is  any  disposi- 
tion to  rigidity  of  the  parts, — either  the  os  uteri,  the  vagina,  or  the  peri- 
neum,— through  fear  of  the  same  dangers.  As  a principle,  it  is  not  usu- 
ally necessary  in  first  children,  and  therefore  this  is  a case  in  which  we 
generally  should  make  an  exception.  It  must  not  be  given  in  any  case 
where  the  lingering  labour  depends  upon  a malposition  of  the  head.  It  may 
be  admissible  occasionally  in  breech  presentations ; but  in  no  case  of  trans- 
verse position  of  the  foetus,  provided  the  term  of  gestation  is  nearly  completed, 
should  we  ever  contemplate  administering  the  ergot.  It  must  only  be  given  in 


Neale  on  the  ergot,  p.  42, 


t On  Uterine  Haemorrhage,  p.  79. 


168 


LINGERING  LABOUR 


cases  where  the  sole  cause  of  delay  is  a torpid  or  feeble  state  of  uterine  ac- 
tion; or  where  it  is  desirable  to  terminate  the  labour  speedily, — and  that  too 
by  means  of  the  natural  powers, — in  consequence  of  haemorrhage.  I have 
found  it  very  useful  in  accidental  haemorrhage  after  the  membranes  have 
been  ruptured ; in  loss  of  blood  under  abortion  also,  where  it  was  impos- 
sible to  empty  the  uterus  by  manual  operation ; and  where  the  patient 
would  perhaps  have  sunk  from  the  continuance  of  the  bleeding. 

But  although  I am  perfectly  convinced  of  the  powers  which  the  ergot 
sometimes  displays  under  parturition,  I am  by  no  means  inclined  to  agree 
with  those  practitioners  who  think  that  this  medicine  will  entirely  super- 
sede the  necessity  of  any  other  means  being  used  in  lingering  labour.  I 
cannot  coincide  in  the  opinion  expressed  by  Mr.  Michell,*  that  its  gene- 
ral introduction  will  so  completely  supersede  the  use  of  the  forceps,  that 
“ he  would  not  be  surprised  if  in  twenty  years  that  instrument  should  be 
known  only  by  name.”  Nor  in  his  remark,  “ that  except  in  the  rare  cases 
in  which  the  Caesarean  operation  was  formerly  recommended,  he  con- 
ceives there  will  now  be  no  occasion  for  instrumental  aid  in  midwifery.” 

Authors  vary  much  in  the  statements  they  furnish  of  their  success  with 
this  grain.  This  discrepancy  may  partly  be  accounted  for  by  the  ergot 
in  some  of  the  trials  not  being  fresh,  since,  by  being  kept  too  long  a time, 
it  loses  its  virtue.  It  may  also  be  owing  partly  to  the  constitution  of  the 
patient  not  being  susceptible  of  its  peculiar  action.  We  know  that  some 
persons  are  not  susceptible  of  the  peculiar  action  of  mercury ; and  we  may 
easily  believe  that  in  the  same  manner  some  constitutions  may  be  insus- 
ceptible to  the  peculiar  action  of  the  ergot  of  rye. 

Stimulating  clysters,  principally  composed  of  the  purgative  salts,  have 
often  been  found  useful  in  exciting  the  uterine  fibres  to  more  powerful 
contraction.  External  means  are  sometimes  had  recourse  to  for  the  same 
purpose.  Warmth,  applied  by  hot  flannels  to  the  hypogastric  region, 
to  the  legs,  the  thighs,  and  the  back,  has  been  tried,  but  has  seldom  been 
found  efficacious  in  restoring  uterine  action,  unless  there  existed  also  at 
the  same  time  depressed  arterial  energy,  or  a cold  surface.  Under  such 
circumstances  we  should  not  only  apply  warmth  externally,  but  give 
warm  diluents,  or  perhaps  stimulants.  Pressure  and  friction  are  found  to 
possess  greater  power  over  the  uterine  fibres  than  warmth  externally 
applied.  The  pressure  of  a bandage,  or  the  hand,  will  often  excite  the 
uterus  to  increased  action  both  before  and  after  the  birth  of  the  child.  It 
will  be  shown,  that  in  cases  of  haemorrhage  after  delivery,  dependent  on 
a flaccid  state  of  the  parietes  of  the  womb,  we  possess  no  more  servicea- 
ble means  to  ensure  their  permanent  contraction  than  the  application  of 


* On  the  Ergot  of  Rye,  1828,  p.  5G. 


FROM  INEFFICIENT  UTERINE  ACTION.  169 


pressure  by  the  grasp  of  the  hand ; and  although  pressure  acts  more  ener- 
getically upon  the  uterus  when  the  organ  is  more  or  less  emptied  of  its 
contents,— especially  after  the  birth  of  the  child,— yet  firm  steady  pressure 
will  sometimes  excite  it  to  more  vigorous  contraction,  even  while  it  con- 
tains the  foetus  within  its  cavity.  Friction  with  the  open  palm  previously 
to  the  birth  of  the  child  is  more  frequently  had  recourse  to  under  this  kind 
of  lingering  labour  than  more  simple  pressure,  and  a most  efficacious 
agent  it  sometimes  proves. 


I am  inclined  to  think  that  electrical  shocks — particularly  derived  from 
the  galvanic  battery — would  excite  the  flagging  powers  of  the  uterus 
under  labour,  and  perhaps  even  induce  action  ab  initio . This  is  a means, 
however,  of  which  I would  not,  in  the  present  state  of  our  knowledge' 
recommend  a trial;  and  I only  judge  by  analogy,  in  consideration  of  the 
influence  the  electrical  fluid  exerts  over  the  nervous  system,  generally, 
and  through  that  system,  over  muscular  fibre. 

We  may  sometimes  also  succeed  in  rendering  the  uterine  contractions 
stronger  and  more  efficient  by  changing  the  patient’s  position,  particularly 
from  the  recumbent  to  the  upright  posture ; and  as  this  is  a very  simple 
means,  as  it  is  often  useful,  and  as  the  change  brings  her  great  relief,  she 
may  be  advised  to  sit,  stand,  or  walk,  as  her  own  inclination  dictates. 
The  effect  is  most  probably  produced  by  the  gravitation  of  the  head  upon 
the  os  uteri. 


Before  concluding  this  part  of  my  subject,  I must  repeat  the  caution 
previously  given  against  unnecessarily  rupturing  the  membranes  during 
the  first  stage  of  labour.  It  has  of  late  become  very  much  the  practice, 
—attributable  in  some  measure,  perhaps,  to  the  recommendations  incul- 
cated by  Professor  Burns* — to  evacuate  the  liqour  amnii  in  all  cases 
where  the  uterus  is  acting  feebly ; and  some  instances  have  come  under 
my  own  observation,  in  which  not  only  has  this  act  disappointed  the 
intention  of  the  operator,  but  been  followed,  after  the  lapse  of  some  time, 
by  such  symptoms  as  required  that  the  labour  should  be  terminated  instru- 
mentally.  I do  not  mean  to  assert  that  a protracted  case  is  always  a 
lecessary  consequence  of  such  interference;  for  in  many  instances  where 
;he  os  uteri  is  perfectly  dilatable,  where  it  has  acquired  a diameter  the 
size  of  a crown,  and  especially  where  there  is  an  excessive  quantity  of 
iquor  amnii  present,  the  evacuation  of  the  water — by  causing  the  head  to 
>ear  more  decidedly  on  the  os  uteri — will  increase  the  vigour  of  the  con- 
ractions,  and  bring  about  a more  speedy  termination.  But  I allude  to  it 
ts  a generally  adopted  principle ; and  cannot  but  consider  that  such  an 


* Principles  of  Midwifery,  5th  ed.,  p.  403. 


22 


170 


LINGERING  LABOUR 


interruption  of  nature’s  ordinances  requires  in  practice  the  greatest  possi- 
ble judgment  and  discrimination. 

Nor  must  I allow  the  custom  of  irritating  the  mouth  and  neck  of  the 
womb  with  the  finger,  and  rubbing  it  down  the  back  of  the  vagina,  along 
the  rectum,  to  pass  unnoticed ; nor  that  still  less  justifiable  mode  of  pro- 
ceeding— the  endeavour  to  dilate  the  os  uteri  by  the  first  two  fingers 
introduced  within  it ; which  last  means  also  has  received  the  sanction  of 
the  deservedly  great  name  of  Professor  Burns,*  as  applicable  to  some 
states  of  the  os  uteri ; but  which  I do  not  feel  myself  warranted  in  men- 
tioning except  in  terms  of  reprobation. 

The  practice  indeed  might  be  followed  with  less  danger,  if  the  cautions 
with  which  the  professor  has  surrounded  it  were  always  borne  in  mind 
and  acted  on;  but  the  chances  are,  that  the  principle  alone  will  dwell 
in  the  memory,  and  little  heed  will  be  taken  of  the  kind  of  cases  in  which 
it  is  recommended  as  useful. 

2d.  Deformity  of  Pelvis.— The  second  cause  of  lingering  labour  embraces 
those  cases  in  which  the  uterus  is  acting  powerfully  and  energetically, 
but  where  there  is  a want  of  due  and  proportionate  space  in  the  passages 
for  the  ready  exit  of  the  child : and  of  these  causes,  distortion  of  the  pelvic 
hones , as  being  one  of  the  most  frequent  and  difficult,  claims  our  first 
attention. 

Three  Varieties.— As  in  a former  part  of  this  publication  I arranged 
pelves  in  general  into  four  classes,  so  we  may  now,  for  practical  purposes, 
divide  distorted  pelves  into  three  varieties,— the  first,  in  which  the  pelvic 
brim  is  so  contracted  as  not  to  permit  any  part  of  the  child’s  head  to 
enter  through  it ; the  second,  which  has  allowed  the  head  to  descend  so 
low  as  to  occupy  the  whole  or  the  chief  part  of  the  cavity,  but  whosq 
outlet  is  too  narrow  to  admit  of  its  escape  ; and  the  third — of  that  inter-j 
mediate  size — which  has  permitted  some  portion  of  the  head  to  enter, 
through  the  brim,  and  partially  to  take  possession  of  the  cavity;  while  the 
principal  bulk  remains  above.  These  three  cases  practically  assume  s 
very  different  character,  and  require  therefore  a distinct  consideration. 

First  Variety. — When  we  have  perfectly  satisfied  ourselves,  by  ar 
examination  per  vaginam,  that  the  pelvis  is  so  diminished  in  its  propor- 
tions that  no  part  of  the  child’s  head  can  pass  through  the  brim,  it 
becomes  our  duty  not  to  allow  the  patient’s  strength  to  be  undermined  by 
the  fatigue  necessarily  attendant  upon  such  a labour ; but  early  to  have 
recourse  to  some  means  for  the  purpose  of  relieving  her : because  it  is 

* Op.  citat.  p.  401.  The  late  Professor  Hamilton,  (Practical  Observations,  1840,  p.  125,; 
by  quoting  Burns’  opinion  and  practice  on  this  subject  at  length,  appears  to  adopt  them  as 
his  own  ; and  we  may  fairly  conclude  that  he  gives  them  the  sanction  of  his  authority. 


FROM  DEFORMITY  OF  THE  PELVIS. 


171 


physically  impossible  for  a head  to  be  eventually  expelled  whole  through 
a pelvis  whose  capacity  in  the  superior  aperture  is  so  contracted  as  not 
to  admit  any  portion  of  it,  after  the  evacuation  of  the  liquor  amnii,  and 
the  full  establishment  of  powerful  expulsive  pains. 

Such  being  the  case,  the  means  to  be  adopted  must  become  a most 
interesting  and  important  question  ; and  if,  upon  a measurement  conducted 
with  the  utmost  care,  we  find  that  there  is  less  space  at  the  brim  than 
three  inches  and  a half  laterally,  by  one  inch  and  three-eighths  in  the 
conjugate  diameter ; or  three  inches  by  one  inch  and  a half ; we  ought  to 
consider  it  our  duty — however  painful  and  appalling  that  may  be — at 
once  to  propose  the  Caesarean  section,  as  the  only  means  by  which  it  is 
possible  to  save  the  mother’s  life ; and  as  offering  also  the  sole  chance  of 
safety  to  the  child.  If  it  be  thought  necessary  that  this  operation  should 
be  performed  at  all,  it  ought  at  any  rate  to  be  undertaken  before  the 
patient’s  system  has  sunk,  from  a long  continuance  of  the  excessive  exer- 
tion of  labour.  This  recommendation  I think  it  right  to  inculcate, 
in  consequence  of  the  difference  so  remarkable  in  the  result  of  the  cases 
operated  upon  in  this  country  and  on  the  continent.  In  the  British  isles, 
out  of  nearly  thirty  operations,  we  have  only  three  instances  of  recovery 
on  record — one  in  which  an  ignorant  midwife  in  Ireland,  named  Donally,* 
officiated ; another  under  the  excellent  care  of  the  late  Mr.  Barlow  ;f  and 
a third,  where  the  operation  was  performed  by  Mr.  Knowles, J of  Birm- 
ingham ; — while,  on  the  continent,  a fortunate  termination  has  repeatedly 
ensued.  How  can  we  account  for  this  discrepancy  ? The  astonishingly 
superior  success  on  the  continent  is  not  to  be  attributed  to  the  climate 
being  more  favourable  to  capital  operations — to  the  human  system  being 
in  a state  to  bear  them  better — nor  to  the  surgeons  abroad  possessing 
either  more  general  scientific  knowledge  as  to  the  mode  of  performing 
dangerous  operations,  better  practical  adaptation  of  that  knowledge,  or 
evincing  greater  care  and  anxiety  about  the  result,  than  obtains  in 
England — but  because  either  the  operation  has  been  performed  early  in 
the  labour,  before  exhaustion  has  supervened ; or  because  it  has  been 
undertaken  in  cases  when  the  constitution  has  not  been  so  fearfully  under- 
mined by  previously  existing  disease.  We  may  reasonably  infer,  indeed, 
that  the  more  distorted  the  person  is,  the  more  violent  must  have  been  the 
affection  under  which  the  system  has  suffered,  and  the  less  power  will  it 
possess  of  bearing  up  against  such  a grievous  shock  as  the  Ca3sarean 

* In  January,  1738-39 — Med.  and  Surg.  Essays.  Edinburgh.  4th.  edit.  vol.  v.  art.  38 ; 
reported  by  Mr.  Duncan  Stewart. 

t In  November,  1793 — Barlow’s  Essays  on  Surgery  and  Midwifery,  p.  355. 

t In  1835 — Transactions  of  the  Provincial  Med.  and  Surg.  Association,  vol.  iv.  p.  377. 


172 


LINGERING  LABOUR 


section  must  occasion.  In  Barlow’s  successful  case,  the  cause  of  the 
extreme  diminution  of  the  pelvis  was  not  disease,  but  a fracture  of  the 
pelvic  bones,  from  which  severe  injury  the  woman  had  perfectly  re- 
covered ; and  in  Mr.  Knowles’  the  operation  was  had  recourse  to  thirty 
hours  after  the  commencement  of  labour,  and  seven  only  after  the  rupture 
of  the  membranes. 

The  fact  is  not  to  be  concealed,  that  in  different  parts  of  Europe,  and 
especially  in  Catholic  countries,  both  has  this  operation  many  times  been 
had  recourse  to,  under  circumstances  in  which  no  British  practitioner 
would  have  considered  himself  warranted  in  proposing  it — where,  indeed, 
there  has  existed  sufficient  available  space  in  the  pelvis  to  admit  of  the 
extraction  of  the  foetus  per  vias  naturales  ;*■ — and  also  that  the  women, 
more  under  the  influence  of  their  clerical  pastors  than  ours  are,  have 
readily  and  cheerfully  submitted,  from  a sense  of  religious  duty,  to  this 
dreadful  expedient,  while  they  still  possessed  considerable  strength,  that 
they  might  not  deprive  their  unborn  children  of  the  benefit  of  admission 
within  the  pale  of  the  Christian  church. 

When  this  means  is  considered  unequivocally  requisite,  then,  by  having 
recourse  to  it  early  in  the  labour,  the  best  chance  is  afforded  to  the  patient 
of  the  preservation  of  her  own  life,  as  also  of  her  infant’s.  Notwithstand- 
ing this,  however,  no  rightly-judging  man  would  venture,  on  his  own 
single  responsibility,  to  urge  the  propriety  of  an  operation  so  unusual  in 
its  necessity,  so  appalling  in  its  character,  and  terrible  in  its  consequences, 
as  the  extracting  a foetus  ex  utero  by  an  extensive  abdominal  incision ; 
but,  before  proceeding  to  its  execution,  he  would  naturally  be  desirous  to 
obtain  the  counsel  and  sanction  of  some  neighbouring  practitioner,  in 
whose  opinion  he  confided. 

These  cases  of  extreme  distortion  are  fortunately  of  rare  occurrence: 
the  operation  of  Csesarean  section,  indeed,  has  not  been  found  necessary 
in  this  extensive  metropolis  for  a great  number  of  years,  and  consequently 

* It  would,  perhaps,  be  unfair  to  adduce,  in  confirmation,  those  cases  in  the  latter  half  of 
the  sixteenth'  century — the  second,  third,  fifth,  and  sixth  of  Rousset,  which  came  under  his 
own  observation,  and  the  ninth  of  .Casper  Bauhine,  (Latin  Translation  of  Rousset  on  the 
Caesarean  Section,)  all  which  women  brought  forth  live  children  per  vaginam  subsequently, 
even  if  they  are  correctly  reported;  because  they  belong  to  the  age  of  barbarous  surgery.  But 
in  the  report  of  the  Obstetric  Clinique,  at  Pavia,  for  1827*28,  will  be  found  a fatal  case  of 
Caesarean  operation  by  Professor  Lovati,  the  dimensions  of  the  patient’s  pelvis  being  two 
inches  and  a half  in  the  sacro-pubic  diameter,  three  and  a half  in  the  oblique,  two  in  the  pubi- 
coxygean,  and  two  and  a half  between  the  ischiatic  protuberances.  (See  Lancet,  August 
15th,  1829.)  Again,  in  the  Medicin.  Zeitung,  January,  1840,  is  detailed  another  fatal  case, 
in  which  the  operation  under  a twin  pregnancy  performed  by  Dr.  Busch,  of  Berlin;  here  the 
pelvis  measured  two  inches  and  a quarter  in  its  conjugate  diameter.  (Medical  Gazette, 
March  13th,  1840.)  Very  many  instances  of  a similar  kind  might  be  quoted. 


FROM  DEFORMITY  OF  THE  PELVIS. 


173 


the  chances  are  many  against  the  probability  of  any  one  person  falling  in 
with  an  instance  where  he  would  think  himself  called  upon  to  advise  it. 
Not  so,  however,  with  the  lesser  degrees  of  diminution  in  the  pelvic 
apertures:  these  we  meet  with  continually;  though  certainly  not  so  often 
in  the  open  country,  among  the  hardy  agricultural  peasantry,  as  among 
the  inhabitants  of  great  and  crowded  cities,  and  the  population  of  manu- 
facturing districts. 

If,  then,  a case  come  under  our  notice  in  which  there  is  more  available 
space  than  that  1 have  just  noted  as  imperatively  requiring  the  excision  of 
the  child  from  the  uterus  through  the  abdominal  parietes ; and  yet  where 
the  pelvis  is  so  small  that  we  are  persuaded  the  child’s  head  cannot  pass 
entire,  provided  it  have  arrived  at  full  intra-uterine  maturity ; — a case, 
for  instance,  in  which  the  conjugate  diameter  at  the  brim  measures  about 
two  inches ; — it  would  still  not  be  right  to  let  the  patient  struggle  very 
long  in  labour  without  means  of  relief  being  used  : but  we  should  perforate 
the  head  while  the  system  yet  retained  its  vigour,  that  we  might  have  the 
advantage  of  full  unimpaired  uterine  energy  to  aid  us  in  our  extractive 
efforts.  I trust  it  may  not  be  for  a moment  imagined  I recommend  that 
perforation  should  be  had  recourse  to  early  in  labour  in  all  cases  where 
we  are  likely  to  find  it  necessary  afterwards.  It  is  only  in  those  instances 
where  a moral  certainty  exists  that  the  child  cannot  pass  unmutilated, 
that  we  are  at  all  authorized  to  adopt  this  extreme  measure,  before  urgent 
symptoms  of  danger  to  the  mother’s  life  have  supervened,  unless  there  be 
the  most  unequivocal  proofs  of  the  child’s  death. 

Fortunately  it  is  not  necessary  to  draw  a minutely  nice  distinction 
between  those  cases  in  which  it  is  desirable  that  craniotomy  should  be 
performed  comparatively  early,  and  those  absolutely  requiring  the  same 
operation  later  in  labour ; because,  inasmuch  as  the  means  used  are  simi- 
lar under  both  circumstances,  it  will  seldom  prove  of  material  importance 
— provided  the  child  must  be  sacrificed — whether  the  dreadful  expedient 
be  undertaken  an  hour  sooner  or  an  hour  later.  But  the  case  is  widely 
different  when  it  becomes  our  painful  duty  to  discriminate  between  a 
pelvis  through  which  a head  can  be  extracted  after  the  brain  has  been 
evacuated,  and  one  that  will  not  allow  the  passage  of  the  child  when 
lessened  even  to  the  utmost  degree  that  art  can  accomplish.  For  it 
would  be  to  the  last  degree  heart-rending  and  painful — after  having  per- 
forated the  skull  and  made  forcible  attempts  to  extract  per  vias  naturales 
— to  discover  that  the  pelvis  did  not  afford  sufficient  room  for  the  com- 
pletion of  delivery ; but  that  the  case  required  to  be  terminated  by  the 
abdominal  incision.  Not  only,  indeed,  must  the  infant  then  necessarily 
be  brought  into  the  world  dead,  but  the  patient  would  be  subjected  to 
much  additional  and  unprofitable  agony  during  our  efforts  at  extraction 


174 


LINGERING  LABOUR 


through  the  pelvis.  A diminished  chance  of  ultimate  recovery  would 
also  be  offered  to  her,  in  consequence  of  the  pain  and  exertion  attendant 
on  o ur  frustrated  endeavours,  and  the  pressure,  and  perhaps  contusion,  to 
which  the  soft  parts  must  have  been  more  or  less  exposed. 

I have  already  laid  it  down  as  a general  principle,  that  unless  there  be 
a clear  available  space  of  three  inches  in  the  conjugate  by  four  in  the 
lateral  diameter  at  the  brim,  we  are  not  to  expect  that  the  child  will  be 
born  without  assistance ; but  it  is  not  merely  because  the  pelvis  is  de- 
formed to  such  an  extent  that  we  are  authorized  to  interfere  while  the 
powers  are  vigorous : because  the  child  may  be  immature ; its  head  may 
be  small ; the  bones  may  be  less  ossified,  and  may  overlap  each  other  more 
than  is  usual ; and  a greater  probability  may  therefore  be  afforded  of  a 
natural  termination  of  the  case.  Under  such  circumstances,  it  becomes 
our  bounden  duty  to  wait  till  the  exertion  that  has  been  sustained  has  pro- 
duced no  small  degree  of  exhaustion,  before  we  have  recourse  to  such  a 
horrible  alternative  as  the  instruments  for  craniotomy  supply.  On  the 
contrary,  however,  if  the  space  exceed  two  inches  but  in  a trifling  degree, 
it  is  very  evident  that  a child,  sufficiently  perfected  in  the  womb  to  sus- 
tain independent  existence,  cannot  be  expelled  whole ; and  we  are  there- 
fore fully  justified,  under  this  particular  degree  of  disproportion,  in  inter- 
fering early — however  revolting  to  our  feelings  it  may  be— lest  our  patient 
should  sink  under  the  effects  of  long-continued  and  painful  toil ; lest  she 
should  sustain  a rupture  of  the  uterus,  or  suffer  such  an  extensive  destruc- 
tion of  the  soft  parts  from  pressure,  as  must  render  her  a burden  to  her- 
self and  an  object  of  compassion  to  her  friends  for  the  remainder  of 
her  life. 

In  the  second  variety , where  the  head  has  entirely  passed  the  pelvic 
brim — has  become  jammed  in  the  cavity,  and,  for  want  of  sufficient  space  t 
in  the  outlet,  cannot  make  its  exit — the  woman  generally  suffers  extreme  j 
pain  not  only  from  uterine  contraction,  but  from  uninterrupted  pressure  on 
the  structures  within  the  pelvis.  We  must  bear  in  mind  that  the  pelvic 
viscera  are  exceedingly  nervous,  very  liberally  supplied  with  blood-vessels, 
and  are  peculiarly  exposed  to  those  unhealthy  actions  inseparable  from  a 
high  state  of  vascularity ; that,  although  they  possess  great  restorative 
power  within  themselves,  inflammation  induced  by  contusion,  the  result  of 
pressure,  is  very  likely  to  terminate  in  suppuration ; and  particularly  in 
gangrene.  When  a disposition  to  sloughing  once  commences,  it  is  impos- 
sible to  say  where  the  destructive  process  may  stop : beginning  in  the 
lining  membrane  of  the  vagina,  all  the  vaginal  coats  may  take  upon  them- 
selves the  same  morbid  condition ; the  bladder  and  rectum  may  be  impli- 
cated, and  the  three  cavities  may  be  thrown  into  one, — than  which  it  is 
impossible  to  conceive  a more  miserable  state  of  human  existence. 


FROM  DEFORMITY  OF  THE  PELVIS.  175 

Whenever  the  head  is  locked  in  the  cavity  of  the  pelvis,  we  must  emi- 
nently fear  contusion,  inflammation,  suppuration,  and  sloughing.  We 
have,  also,  to  dread  injury  to  the  bladder : — that  organ  may  burst,  or  fatal 
inflammation  may  occur,  consequent  upon  its  over-distention.  There  is, 
likewise,  great  danger  to  the  child,  from  the  compression  which  the  brain 
must  suffer,  under  impaction ; as  well  as  from  the  pressure  to  which  the 
funis  umbilicalis  must  be  exposed. 

This  case,  then,  is  one  of  a very  dangerous  and  difficult  character ; and 
it  becomes  a most  delicate  question,  how  long  we  shall  allow’  nature  to 
struggle  unaided ; — and  whether,  at  any  particular  period  of  time,  we 
shall  have  recourse  to  instrumental  means.  Many  rules  have  been 
laid  down  for  our  guidance  under  this  emergency,  for  the  consideration 
of  which  an  opportunity  will  be  afforded  in  a subsequent  part  of  this 
work. 

I have  considered  that  the  third  variety , where  the  head  is  partly  pro- 
truded through  the  brim,  the  vertex  dipping  into  the  cavity,  while  the 
principal  bulk  remains  above.  A case  in  which  the  pelvis  measures  about 
three  inches  in  its  conjugate  diameter,  is  of  this  description.  But  it  can- 
not be  impressed  too  forcibly  or  too  frequently  on  the  mind  of  the  student, 
that  although  we  know  the  size  of  the  pelvis  accurately,  and  have  ascer- 
tained beyond  a doubt  that  its  measurement  is  even  rather  below  three 
inches  than  above  it,  we  are  not,  on  that  account  alone,  warranted  in 
taking  an  instrument  in  hand : for  it  must  have  occurred  to  every  practi- 
cal man  frequently  to  have  observed  the  head  wonderfully  adapt  itself  to 
the  irregularities  of  the  pelvis;  so  that  eventually  it  makes  its  exit,  under 
circumstances  which  a few  hours  before  allowed  of  no  expectation,  and 
but  little  hope,  that  a natural  and  unaided  termination  would  be  effected. 
We  must  not,  therefore  apply  instruments  merely  because  there  is  a small 
pelvis,  provided  it  be  moderately  capacious ; but  we  must  give  a full  and 
fair  trial  to  the  powers  of  the  uterus ; and  watching  attentively  both  the 
progress  of  the  head,  and  the  effects  of  the  continued  efforts  on  the  mother’s 
system,  hold  ourselves  in  readiness  to  terminate  the  labour  on  the  first 
accession  of  such  symptoms  as  may  bring  her  life  into  present  jeopardy. 
By  some  we  are  recommended,  in  cases  likely  to  be  rendered  difficult  and 
protracted  by  the  slighter  degree  of  distortion, — embraced  under  the  head 
we  are  now  discussing, — to  introduce  the  hand  into  the  uterus,  grasp  a 
foot,  oblige  the  foetal  body  to  revolve  on  its  own  axis,  and  bring  the  breech 
into  the  pelvis,  terminating  the  labour  by  the  operation  of  turning .*  I 
cannot  find  language  sufficiently  strong  in  which  to  deprecate  this  mode 
of  proceeding,  as  a general  principle.  The  dangers  which  envelope  it 


* Vide  Baudelocque,  parag.  1294. 


176 


LINGERING  LABOUR 


are  many  and  great,  both  to  the  mother  and  her  infant,  and  have  already 
been  partially  glanced  at.  I have  good  reason  to  believe,  and  to  hope 
indeed,  that  such  a means  of  concluding  such  a case  is  now  entirely 
exploded  from  the  practice  of  the  well-informed  obstetrical  surgeon. 

3d.  Tumours  in  the  pelvis. — The  third  cause  of  lingering  labour  is  the  pre- 
sence of  tumours  in  the  cavity  of  the  pelvis.  The  tumours  which  may 
impede  parturition  vary  exceedingly  in  their  nature,  consistency,  and  size  ; 
sometimes  they  possess  the  solidity  of  bone  itself ; at  others,  their  contents 
are  of  the  most  fluid  character.  According  to  their  size  and  unyielding 
nature,  will  be  the  difficulty  which  they  occasion. 

Exostosis. — The  most  solid  of  all  the  tumours  that  we  meet  with  in  the 
pelvis,  is  a knobby,  bony  growth,  taking  its  origin  from  some  portion  of  the 
parietes  themselves; — an  exostosis.  But  it  is  fortunately  of  very  rare 
occurrence ; indeed,  so  infrequent,  that  I have  myself  never  met  with  an 
instance.  It  is  generally  situated  at  the  back  part,  behind  the  rectum, 
and  springs  from  the  cavity  of  the  sacrum.  This  kind  of  tumour  we  shall 
mostly  be  able  to  discriminate  by  its  situation,  its  extreme  hardness,  the 
irregularity  of  its  surface,  its  immobility,  its  knotty  feel,  and  insensibility 
to  pressure. 

Treatment. — Our  treatment  of  a case  rendered  lingering  by  the  presence 
of  a disease  of  this  description,  will  altogether  depend  upon  the  size  of  the 
growth  itself.  If  it  be  very  small,  it  is  probable  that  the  head  may  pass 
without  assistance ; but  if,  on  the  contrary,  it  be  large,  occupying  a consi- 
derable space — since  it  would  be  impossible  to  remove  it  by  operation,  so 
as  to  render  the  cavity  more  capacious — we  must  be  guided  by  the  com- 
mon rule,  (provided  there  be  the  most  distant  probability  of  the  child’s 
passing,)  that  of  waiting  until  symptoms  appear  which  demand  delivery; 
and  according  to  the  magnitude  of  the  tumour  we  must  select  our  means : 
the  forceps,  long  or  short,  if  they  offer  a fair  chance  of  suecess,  should  be  ! 
preferred ; if  neither  of  those  instruments  avail  us  any  thing,  we  must  call 
in  the  aid  of  the  death-inflicting  perforator.  It  is  certainly  possible  that  an 
exostosis  may  have  attained  such  a size  as  not  to  leave  an  inch  and  a 
quarter  of  space  between  the  anterior  and  posterior  parietes  of  the  pelvis. 
In  such  a formidable  case, — as  we  should  not  be  able  to  extract  the  foetus 
through  the  vagina,  even  although  we  might  succeed  in  diminishing  its 
volume  to  the  smallest  practicable  size, — we  should  be  compelled  to  have 
recourse  to  the  Caesarean  section. 

Schirrhous  or  dropsical  ovary. — The  ovary  is  liable  to  diseases  of 
various  kinds,  of  which  dropsy  and  schirrhous  are  the  most  frequent. 
Under  both  these  affections  the  gland  becomes  very  considerably  enlarged; 
and  when  it  is  the  subject  of  dropsy,  its  coats  are  extended  to  an  enor- 


FROM  PELVIC  TUMOURS. 


177 


mous  size,  containing  in  some  instances  many  gallons  of  fluid.  We  can- 
not be  surprised,  then,  at  the  impediment  offered  to  the  child’s  birth,  if 
pregnancy  and  an  ovarian  tumour  exist  together.  When  enlarged  by 
disease,  the  ovary  generally  rises  by  degrees  from  the  pelvic  into  the 
abdominal  cavity : but  occasionally  it  becomes  bound  down  by  adhesive 
inflammation  to  the  subjacent  parts ; and  if,  under  such  a state,  the  woman 
conceives  and  carries  her  fcetus  to  the  full  period,  her  labour  must  neces- 
sarily be  difficult.  Even  if  it  be  not  confined  to  the  pelvis  by  adhesion, 
it  may  be  found  in  labour  occupying  the  cavity  more  or  less,  never  having 
commenced  its  ascent  into  the  abdomen ; being  prevented,  perhaps,  by  the 
gravid  uterus,  which  has  already  taken  possession  of  that  space.  Or  a 
portion  of  the  tumour  may  have  prolapsed,  and  subsided  during  gestation ; 
for  pregnancy  by  no  means  interferes  with  the  continued  progress  of  such 
an  enlargement. 

The  situation  of  this  tumour  is  also  external  to  the  vaginal  coats,  and 
it  is  generally  to  be  felt  towards  the  posterior  part  of  the  pelvis.  It  will 
probably  be  somewhat  moveable ; it  will  neither  be  so  hard  nor  so  irregu- 
lar as  an  exostosis,  and  will  most  likely  possess  more  sensibility. 

Plate  XXX.  fig.  92,  displays  an  enlarged  ovarium  occupying  the  pelvic 
cavity,  and  impeding  the  descent  of  the  head.  The  principal  features  of 
this  plate  are  copied  from  a drawing  given  by  Merriman  in  his  excellent 
synopsis.  A the  os  pubis,  B the  enlarged  ovarium  lying  in  the  cavity  of 
the  sacrum,  between  the  rectum  C and  the  posterior  wall  of  the  vagina 
D,  consequently  outside  the  vaginal  canal. 

Treatment. — The  treatment  under  such  circumstances  must  likewise 
depend  upon  the  size  and  solidity  of  the  tumour.  If  its  true  character 
be  detected  before  the  head  has  become  much  engaged  in  the  pelvic 
brim,  we  may  possibly, — provided  it  be  free  and  not  adherent, — suc- 
ceed by  steady  pressure  in  pushing  it  up  above  the  brim,  and  conse- 
quently out  of  the  way  of  the  head’s  advance.*  If  we  cannot  ac- 
complish this  object,  we  must  act  upon  common  principles,  and  wait 
until  symptoms  appear  requiring  our  interference : for  if  the  tumour  be  soft, 
it  is  very  probable  that  the  descending  head  will  compress  it  into  a flat- 
tened form,  or  squeeze  a part  of  its  contents  upwards  above  the  brim,  and 
thus  diminish  its  resisting  power : while,  on  the  contrary,  if  the  disease  be 
of  a solid  kind,  it  would  be  wrong  to  have  recourse  either  to  obstetrical 


* Merriman  (Med.  Chirurg.  Transactions,  vol.  x.  p.  61)  gives  a case  in  which  he  pushed  a 
tumour,  occupying  the  pelvis  in  labour,  above  the  brim,  without  difficulty,  and  thus  procured 
room  for  the  birth  of  a living  child.  A patient  of  my  own  has  an  ovarian  tumour  which  has 
impeded  delivery  in  two  of  her  labours;  on  both  of  which  occasions  I succeeded,  with  very 
little  trouble,  in  raising  it  out  of  the  way  of  the  head’s  descent, 

23 


178 


LINGERING  LABOUR 


or  surgical  instruments,  until  necessity  cempelled  us.  When  this  neces_ 
sity  appears,  it  will  be  for  us  to  determine  whether  we  shall  puncture  or 
excise  the  tumour,  or  whether  we  shall  extract  the  child  by  instrumental 
aid.  It  is  impossible  to  lay  down  any  general  rule  applicable  to  every 
individual  case ; but  we  may  establish  the  principle,  that  if  the  swelling 
possess  the  least  evident  degree  of  fluctuation,  a puncture  should  be  made 
into  its  substance  by  means  of  a trochar  introduced  through  the  vagina  or 
rectum.  Even  if  the  disease  be  simple  dropsy,  we  must  not  expect  to 
evacuate  all  the  fluid,  because  most  probably  the  tumour  will  be  formed  of 
separate  cysts  of  different  sizes,  possessing  no  communication  with  each 
other : but  we  may  let  out  a part  of  the  contained  water ; and  if,  fortu- 
nately, the  cyst  we  puncture  should  be  large,  we  shall  reduce  the  general 
bulk  so  much  as  to  afford  a fair  chance  for  the  head  to  pass.  Should  the 
contents,  however,  be  found  of  a semi-solid  or  gelatinous  consistence,  too 
thick  to  run  through  a trochar,  it  would  then  be  right  to  make  an  incision 
into  the  mass  from  the  vagina,  of  half  an  inch  or  an  inch  in  extent,  with 
the  hope  of  entirely  evacuating  the  sac.  If,  lastly,  by  these  means  we 
effect  no  material  diminution  in  its  size,  we  must  determine  whether  we 
should  extirpate  it  through  the  vagina,  or  deliver  the  child  either  by  the 
forceps,  or  by  opening  the  head.  If  there  be  the  least  chance  of  delivery 
being  effected  by  the  forceps,  that  would  be  preferable  to  either  of  the 
other  methods ; but  if  the  forceps  fail  us,  we  have  no  choice  left,  except 
either  dissecting  out  the  tumour,  or  perforating  the  skull.  The  removal 
of  the  diseased  mass  would,  no  doubt,  be  both  very  difficult  and  hazardous 
on  many  accounts ; and  horrible  as  the  alternative  is,  I should,  in  my  own 
practice,  rather  destroy  the  child  than  subject  the  mother  to  such  a for- 
midable operation. 

Schirrhous  glands. — Another  species  of  tumours  offering  an  impedi- 
ment to  the  head  consists  in  the  glands  situated  along  the  hollow  of  the 
sacrum  having  become  affected  with  schirrhous  enlargement. 

Schirrhous  glands  may  be  detected  by  their  situation,  irregularity,  and 
hardness — by  their  being  very  sensitive — by  their  forming  a chain  of  in- 
durated tubercles  also  external  to  the  vaginal  coats — and  by  their  being 
more  or  less  firmly  attached  to  the  surrounding  structures.  Concerning 
the  treatment  of  such  unusual  cases,  I have  nothing  to  add  to  what  I have 
just  advanced  in  regard  to  enlarged  ovaries. 

Abscesses  will  occasionally  form  in  the  pelvis  during  pregnancy,  and 
in  this  case  there  would  be  decided  fluctuation  present.  An  abscess  might 
be  distinguished  from  a dropsical  ovary  by  its  situation,  perhaps — its  ex- 
cessive tenderness  on  pressure — and  its  formation  haying  been  preceded 
and  accompanied  by  symptoms  of  local  inflammation,  and  indications  of 


FROM  PELVIC  TUMOUR  S. 


179 


the  suppurative  action.  An  error  in  diagnosis,  however,  would  be  but  of 
little  consequence,  since  the  treatment  employed  in  the  two  cases  must  be 
essentially  and  positively  the  same.  There  could  be  no  hesitation  in  punc- 
turing such  a swelling  through  the  vagina,  and  letting  out  the  pus.  The 
difficulty  would  then  be  over,  and  the  head  would  most  probably  pass. 

Polypi. — Tumours,  however,  formed  within  the  uterus,  or  growing  from 
the  internal  surface  of  the  vagina,  will  sometimes  impede  the  passage  of 
the  head.  These  are  of  a polypus  character ; they  are  fleshy  and  solid 
in  their  structure,  and  grow  occasionally  to  an  amazing  size.  It  is  singu- 
lar that  the  presence  of  an  excrescence  of  this  kind  inf  the  uterus  does  not 
prevent  conception  taking  place;  which  fact  I have  myself  had  more  than 
one  opportunity  of  witnessing.  Plate  XXXI.  fig’.  93,  shows  a polypus  A* 
lying  in  the  vagina,  and  filling  the  pelvis  to  such  an  extent  as  to  prevent 
the  passage  of  the  head.  B the  posterior  wall  of  the  vagina,  behind  the 
tumour,  which  consequently  is  situated  wiihin  the  vaginal  cavity. 

A case  is  detailed  by  my  father,*  which  came  under  his  observation, 
as  well  as  mine,  in  1824,  that  offers  some  valuable  points  of  practical 
instruction.  He  had  been  requested  to  superintend  the  labour  of  a woman 
pregnant  of  her  third  or  fourth  child,  but  was  from  home  when  the  mes- 
senger arrived  to  summon  him  ; I consequently  went  in  his  stead.  I found 
her  suffering  severe  pains,  and  using  forcible  bearing-down  efforts,  under 
the  belief  that  the  child  wras  about  to  pass  immediately.  On  making  the 
examination,  I instantly  detected  that  the  pelvic  cavity  was  occupied 
almost  entirely  by  a solid  fleshy  tumour,  much  larger  than  a goose’s  egg, 
which  was  pressing  considerably  on  the  perineum : the  os  uteri,  at  the 
brim  of  the  pClvis,  was  dilated  to  about  the  diameter  of  a crown  piece ; 
and  the  membranes,  unruptured,  were  being  forcibly  propelled  against  the 
upper  part  of  the  tumour  with  the  return  of  each  uterine  contraction.  I 
was  at  no  loss  to  determine  that  the  tumour  was  of  a polypus  character, 
by  its  firm  consistence,  its  shape,  its  situation  within  the  vaginal  cavity, 
and  its  attachment  within  the  os  uteri.  The  mouth  of  the  womb  dilated 
rapidly  the  membranes  burst  speedily ; and  in  less  than  an  hour  after  my 
arrival,  the  head,  under  the  action  of  powerful  throes,  forced  the  principal 
bulk  of  the  tumour  external  to  the  vulva,  (which  still,  nevertheless,  re- 
tained its  attachment  to  the  uterus  by  the  stem)  and  itself  instantly 
followed.  At  the  same  moment  my  father  entered  the  room,  and  with 
myself,  had  an  opportunity  of  examining  the  tumour  lying  forth  between 
the  thighs.  Now,  however,  that  the  difficulty,  as  far  as  regarded  the 


* Practical  Observations  ih  Midwifery,  Part  II.  p.  473. 


180 


LINGERING  LABOUR 


birth  of  the  child,  was  removed,  it  became  a question  in  what  manner  the 
polypus  should  be  treated ; — whether  it  should  be  taken  away  immediately 
by  a knife,  after  having  secured  the  vessels  of  the  stem  by  a ligature ; or 
whether  it  should  be  returned  into  the  vagina,  and  a future  opportunity 
taken  of  tying  it,  according  to  the  commonly-adopted  method.  In  favour 
of  the  first  suggestion,  it  might  have  been  urged  that  the  tumour  was  at 
that  time  so  completely  under  control,  as  to  render  the  operation  one  of 
the  easiest  description ; and  against  it,  that  the  difficulty  of  surrounding 
the  stem  of  a polypus,  lying  in  the  vagina,  by  means  of  the  double  canula,  is 
but  trifling;  and,  in  the  case  before  us,  might  easily  be  accomplished  at 
any  time.  Besides, — the  uterus  being  so  eminently  disposed  to  take  upon 
itself  inflammatory  action  in  all  cases  after  delivery, — there  was  great 
danger  lest  the  double  irritation  of  the  inflicted  wound  and  the  attached 
ligature  should  excite  a disease  which  it  would  be  difficult  to  keep  in 
check.  Again,  it  seemed  likely,  that,  as  the  adventitious  growth  was 
nourished  by  the  same  vessels  which  supplied  the  uterus,  these  vessels  had 
become  enlarged  in  a proportion  somewhat  equivalent  to  the  increase  in 
the  calibre  of  the  uterine  vessels  themselves.  If  such  were  the  case,  it 
was  fair  to  infer  that,  as  the  uterine  vessels  shrank  after  delivery,  the 
vascularity 'of  the  polypus  would  also  be  materially  diminished;  and  that 
this  diminution  in  the  bulk  of  the  morbid  growth  would  render  its  removal 
altogether  less  formidable.  These  reasons  induced  us  to  delay  the  opera- 
tion at  least  until  the  changes  consequent  on  delivery  were  accomplished, 
and  the  puerperal  state  had  terminated.  The  result  both  justified  our 
expectations,  and  confirmed  the  correctness  of  our  reasoning;  for  my 
father  made  several  vaginal  examinations  during  the  few  first  weeks  after 
delivery,  and  satisfied  himself  that,  as  the  uterus  contracted,  the  tumour 
also  lessened  in  size.  After  the  lapse  of  nearly  four  months — no  symp- 
toms appearing  in  the  mean  time  to  call  for  earlier  interference — the 
polypus  was  tied  in  the  usual  manner,  and  sloughed  off  in  five  days;  and 
at  the  time  of  its  removal,  its  size  was  scarcely  so  great  as  a walnut 
divested  of  its  outer  husk. 

Diagnosis. — There  can  be  but  little  difficulty  in  detecting  a case  of  this 
kind.  The  pear-shaped,  solid,  tumour  will  be  felt  more  or  less  occupying 
the  cavity  of  the  vagina,  attached  by  its  pedicle  either  to  the  vaginal 
membrane  itself,  or  to  the  uterus ; or  the  stalk  will  be  lost,  as  it  were,  in 
the  cavity  of  the  uterus,  and  the  point  of  its  connexion  with  the  healthy 
structures  will  not  be  discernible ; we  shall  be  able  to  pass  the  finger  all 
around  it,  to  encompass  its  bulk  and  determine  its  shape. 

Treatment. — Should  a tumour  of  this  description  have  acquired  such  a 
magnitude  as  to  offer  great  resistance  to  the  passage  of  the  child’s  head, 


TLXXXL 


Sinalair's  JTjiih. 


FROM  PELVIC  TUMOURS. 


181 


we  must  to  a certain  extent  follow  the  common  principles,  already  incul- 
cated ; and  give  nature  a fair  trial,  in  the  hope  of  witnessing  a termination 
such  as  I have  just  detailed.  But  if  the  powers  begin  to  fail — if  the  parts 
become  tumid,  hot,  or  dry,  showing  a disposition  to  inflame,  then  it  will 
be  necessary  to  interfere ; and  the  question  will  naturally  arise,  whether  we 
shall  remove  the  tumour,  or  deliver  the  patient  by  instrumental  means. 
If  we  can  deliver  easily  by  the  forceps,  we  had  better  have  recourse  to 
them,  because  they  do  no  injury  either  to  the  child  or  mother ; but  if 
delivery  is  impracticable  through  their  agency,  rather  than  perforate  the 
skull,  a ligature  should  be  put  around  the  stem,  and  the  tumour  should  be 
cut  off  below.  On  the  removal  of  the  morbid  mass,  the  child’s  head  will 
probably  be  expelled. 

Descent  of  the  bladder. — The  bladder  sometimes  prolapses  before  the 
head ; of  which  accident  I have  seen  many  instances.  Much  embarrass- 
ment, and  no  small  danger,*  may  be  the  consequence  of  the  case  being 
overlooked  or  mistaken.  This  usually  occurs  in  the  early  period  of 
labour,  before  the  head  has  engaged  in  the  pelvic  cavity,  and  depends  on 
pressure  exerted  by  the  descending  head  upon  the  fundus,  or  middle  por- 
tion of  the  organ,  at  a time  when  it  is  partially  distended  with  urine. 
Plate  XXXI.  fig.  94,  shows  the  bladder,  A,  thus  prolapsed,  a part  of  it 
being  retained  in  its  ordinary  position  by  its  attachment  to  the  abdominal 
parietes. 

The  symptoms  attendant  on  prolapsed  bladder  are  very  distressing; 
there  is  a painful  sensation  of  fulness,  tension,  and  pressure  downwards, 
in  the  situation  of  the  pubes ; with  a feeling  of  dragging  from  the  navel, 
or  rather  the  mid-space  between  the  navel  and  pubic  symphysis;  constant 
desire  to  micturate ; and  inability  to  void  urine  on  the  exercise  of  the  will* 
and  sometimes  an  involuntary  escape  on  each  return  of  uterine  contrac- 
tion. On  examination  per  vagin am,  the  finger  will  detect  a soft  fluctu- 
ating tumour  filling  up  the  anterior  part  and  one  or  both  sides  of  the  pelvic 
cavity,  below  the  foetal  head ; and  the  patient  will  complain  if  steady 
pressure  be  made  on  it.  The  introduction  of  the  catheter,  which  may  be 
easily  accomplished,  will  at  the  same  time  withdraw  the  fluid,  cause  the 
swelling  to  disappear,  and  relieve  the  characteristic  suffering.  Keeping 


* See  Merriman’s  Synopsis,  p.  202,  for  a case  where  an  inconsiderate  practitioner  thrust 
a sharp  instrument  into  the  bladder,  under  the  belief  that  the  swelling1  was  a hydrocephalic 
head.  Hamilton  (M.  S.  Lectures,  1821)  used  to  tell  of  another  equally  rash,  who  mistaking 
the  prolapsed  bladder  for  the  membranes  of  the  ovum,  punctured  it,  with  the  intention  of 
letting  off  the  liquor  amnii.  I can  readily  imagine  that  the  distended  organ  in  this  situation 
might  be  mistaken  for  a dropsical  ovary,  and  its  contents  discharged  by  puncture  or  incision, 
if  the  precaution  of  introducing  the  catheter  were  not  used. 


182 


LINGERING  LABOUR 


€ 


in  mind  the  possibility  of  the  bladder  being  pressed  downwards  as  de- 
scribed, it  is  an  essential  duty  never  to  puncture  any  fluctuating  pelvic 
tumour,  without  being  first  assured  that  it  is  not  vesical,  by  the  removal 
of  the  urine  by  means  of  the  catheter.  A chronic  prolapsus  of  the  bladder 
is  likely  to  follow  its  accidental  descent  in  labour; 

Scybal^e. — There  is  still  another  adventitious  tumour  which  may  impede 
the  passage  of  the  child ; — a collection  of  fasces  in  the  rectum.  It  is  not 
usual  to  meet  with  a case  of  this  kind  in  the  higher  classes  of  society ; but 
it  is  by  no  means  uncommon  among  the  lower  orders ; and  I have  seen 
more  than  one  instance,  in  which  the  mass  contained  within  the  rectum 
was  so  hard  and  so  large,  as  for  some  time  to  obstruct  the  exit  of  the 
heado 

It  is  not  likely  that  we  shall  confound  this  cause  of  protraction  with  any 
morbid  pelvic  growth ; because  by  passing  the  finger  into  the  vagina, 
and  tracing  the  rectum,  that  gut  will  be  felt  bulging  forward;  but  if  any 
doubt  remain,  an  examination  of  the  rectum  itself  will  generally  dis- 
sipate it. 

Treatment. — The  obvious  indication  here  is,  to  evacuate  the  bowel  of 
its  contents.  This  may  be  done  by  throwing  up  twelve  or  fourteen  ounces 
of  warm  water,  so  as  to  liquify  the  faeces  and  dislodge  them.  But  cases 
have  occurred  in  which  all  attempts  to  inject  a fluid  were  rendered  nuga- 
tory, in  consequence  of  the  hardness  and  compactness  of  the  mass.  It 
has  been  advised  that  we  should,  in  such  an  aggravated  state,  endeavour 
to  empty  the  rectum  by  means  of  the  handle  of  a spoon.  It  need  scarcely 
be  remarked,  that  this  cause  of  difficulty  may  be  entirely  obviated  by  pro- 
per attention  being  paid  to  the  due  evacuation  of  the  canal  during  the  last 
five  or  six  weeks  of  utero-gestation. 

4th.  Rigidity  of  the  soft 'parts. — A fourth  cause  of  lingering  labour  consists 
in  rigidity  of  the  soft  parts  through  which  the  child  must  pass : and  this 
is  a subject  of  great  interest,  because  of  its  frequent  occurrence,  the  exces- 
sive pain  generally  attendant  upon  the  case,  and  the  difficulty  that  is  often 
experienced  in  overcoming  the  resistance  occasioned. 

It  has  been  already  shown,  that  rigidity  may  exist  in  the  os  uteri, 
the  vagina,  or  the  perineum,  separately ; but  we  usually  observe  that 
when  one  part  is  affected,  all  the  structures  partake  more  or  less  of  the 
unhealthy  condition  ; so  that  even  after  the  os  uteri  is  fully  distended,  much 
delay  and  distress  is  experienced  in  the  dilatation  of  the  vagina  and  exter- 
nal parts. 

Women  who  are  bearing  their  first  child,— especially  if  they  have 
entered  the  middle  period  of  life,— those  who  possess  a strong  constitution 


FROM  RIGIDITY  OF  THE  OS  UTERI. 


1S3 


engrafted  on  a vigorous  and  rigid  fibre,  are  the  most  likely  to  suffer  from 
this  cause  of  protraction.  To  add  to  the  distress,  it  is  very  usual,  when 
extraordinary  rigidity  exists,  for  the  membranes  to  break  early  in  the 
labour ; and  this  unfortunate  occurrence  much  aggravates  both  the  pain 
endured,  and  the  tediousness  of  the  dilating  process. 

Cases  rendered  lingering  by  preternatural  rigidity  are  exceedingly  per- 
plexing, and  often  very  unmanageable ; they  are  frequently  followed  by 
inflammation  of  the  uterus  or  vagina,  by  abscess,  and  sloughing.  As  each 
of  these  states  deserves  a distinct  consideration,  I shall  first  call  my  reader’s 
attention  to  rigidity  of  the  os  uteri. 

Rigidity  of  the  os  uteri. — When  a woman  has  borne  a number  of 
children,  the  uterine  mouth  generally  dilates  very  readily,  and  therefore 
we  may  expect  to  meet  with  this  cause  of  difficulty  more  frequently  in 
primary  labours ; but  this  is  by  no  means  universally  the  case.  A very 
uncommon  exception  to  this  general  rule  came  under  my  observation  on 
one  occasion.  I attended  an  unmarried  woman,  pregnant  with  her  first 
child,  who  was  in  as  comfortable  circumstances  as  her  situation  would 
admit  of.  When  labour  set  in,  the  os  uteri  opened  with  no  difficulty,  and 
the  child  was  born  in  four  or  five  hours  from  the  time  I was  summoned. 
She  again  became  pregnant,  but  it  was  under  very  different  circumstances ; 
and  her  mind  was  much  more  disturbed  than  on  the  first  occasion.  On 
the  accession  of  labour  the  membranes  broke  early  ; the  pains  soon  became 
exceedingly  violent ; the  head  was  urged  powerfully  against  the  undilated 
and  rigid  os  uteri;  irregular  muscular  spasms  supervened ; and  at  the  end  of 
about  fifty  hours  from  the  rupture  of  the  membranes, — when  the  dilatation 
acquired  did  not  exceed  the  diameter  of  a shilling,  while  I was  instituting 
an  examination,  in  the  acme  of  a strong  pain,  with  the  greatest  possible 
care,  I felt  the  os  uteri  split  on  the  right  side,  and  I traced  the  rent  consi- 
derably upwards  through  the  cervix.  At  the  same  moment  the  head 
passed  into  the  vagina,  and  was  expelled  by  a continuance  of  the  same 
contraction.  During  the  process  of  this  labour,  I bled  the  patient  to  syn- 
cope three  different  times,  and  exhibited  opium  freely,  my  mind  being 
impressed  with  a dread  of  the  very  accident  which  occurred.  It  is  an 
instructive  case,  because  it  proves,  that  although  an  os  uteri  has  relaxed 
and  dilated  readily  in  a first  labour,  it  may  on  after  occasions  possess  a 
high  degree  of  unnatural  rigidity, — and  that,  too,  independently  of  the  exist- 
ence of  any  discoverable  disease  in  the  organ  itself.  It  proves,  also,  that 
the  much  vaunted  power  both  of  bleeding  and  opium  will  not  always  avail 
in  removing  rigidity.  The  poor  creature  died  on  the  fourth  day  after 
delivery,  of  uterine  inflammation. 

More  recently  I was  requested  to  take  charge  of  a lady,  the  mother  of 


184 


LINGERING  LABOUR 


nine  children,  who  was  suffering  much  from  anasarca,  with  the  abdomen 
immensely  distended,  partly  from  the  enormous  size  which  the  uterus  had 
acquired,  and  partly  from  fluid  in  the  peritoneal  cavity.  The  os  uteri, 
from  the  beginning  of  labour,  bore  a thick,  soft,  puffy,  cedematous  cha- 
racter; its  dilatation  proceeded  slowly  and  painfully;  the  membranes 
broke  at  one  in  the  morning,  when  it  was  dilated  to  the  size  of  a crown. 
At  four  its  diameter  was  very  little  more;  and  while  I was  in  the  act  of 
examining,  during  a strong  pain,  as  in  the  last-mentioned  case,  I felt  it 
tear  at  the  back  part,  in  a direction  upwards.  The  finger,  on  being  with- 
drawn, was  tinged  with  blood.  The  child  was  born  at  five ; its  weight 
was  twelve  pounds  and  three  quarters.  The  shoulders  were  so  broad  as 
to  give  me  much  trouble  in  their  extraction.  During  the  interval  between 
the  birth  of  the  head  and  passage  of  the  shoulders,  the  child  gasped  once ; 
but  died  immediately  on  its  expulsion.  The  uterus  contracted  and  expelled 
the  placenta ; there  was  some  after-haemorrhage,  though  not  to  an  alarm- 
ing extent.  The  patient  suffered  neither  pain  nor  any  kind  of  distress  till 
the  expiration  of  thirty  hours,  when  she  was  seized  with  a violent  rigour, 
followed  by  copious  perspiration.  The  pulse  rapidly  rose  to  one  hundred 
and  forty,  and  one  hundred  and  fifty  beats  in  a minute ; the  skin  became 
hot ; great  loss  of  power  supervened ; the  tongue  and  hands  were  very 
tremulous ; the  nights  were  passed  without  sleep  ; the  breathing  was  quick, 
but  not  painful ; no  milk  was  secreted ; yet  the  lochia  flowed  naturally ; 
the  stomach  never  rejected  its  contents ; the  urine  and  faeces  passed  with- 
out pain ; and  there  was  but  little  uterine  tenderness : but  the  countenance 
gradually  became  more  depressed  and  anxious ; and  on  the  fifth  morning 
after  her  delivery,  she  was  suddenly  seized  with  great  difficulty  of  breath- 
ing, and  died  in  an  hour  from  the  accession  of  this  symptom. 

To  another  case  I was  called,  in  consultation,  where  the  os  uteri  had 
entirely  sloughed  off,  in  consequence  of  the  strong  pressure  to  which  it 
had  been  exposed  for  a great  length  of  time.  This  fact,  sufficiently  evi- 
dent before  delivery,  I had  an  opportunity  of  ascertaining  beyond  a doubt 
by  dissection.  There  existed,  also  a slightly  distorted  pelvis.  A case 
occurred  to  Mr.  Scott,  of  Norwich,  in  which  the  os  uteri  together  with  a 
considerable  portion  of  the  cervix  was  torn  off  by  the  force  of  the  uterine 
contractions,  and  came  away  in  an  entire  state,  presenting  the  appearance 
of  a circular  fleshy  substance,  having  a central  aperture.  The  patient 
eventually  recovered,  after  hovering  for  a long  time  on  the  brink  of  de- 
struction.* These  last  two  accidents  occurred  under  first  labours. 

Disease  in  the  os  uteri  causing  rigidity. — Sometimes  the  os  uteri  is 


Med.  Chirurg.  Transact,  vol.  xi.  p.  292. 


FROM  DISEASE  OF  THE  OS  UTERI. 


185 


rigid  from  disease,  particularly  schirro-cancer,  and  cauliflower  excres- 
cence-states which  do  not  prevent  conception,  but  must  give  rise  to 
more  or  less  difficulty  in  labour.* 

* It  has  happened  to  me  to  see  two  instances  of  labour  in  which  the  mouth  and  neck  of 
the  womb  were  extensively  affected  with  cancerous  ulceration;  and  one  in  which  a cauliflower 
excrescence  of  two  years’  growth,  and  of  large  size,  was  attached  to  the  same  organ.  The 
first  two  cases  occurred  in  patients  of  the  Royal  Maternity  Charity,  and  I had  been  attending 
both  for  some  weeks  before  labour.  One  of  these  women  (in  whom  the  whole  disc  of  the  os 
uteri  was  destroyed  by  malignant  ulceration,  the  vagina  being  extensively  affected  also)  went 
into  labour  rather  prematurely;  the  process  was  so  rapid,  that  the  child  was  born  before  the 
midwife  could  arrive.  The  woman  died  in  the  second  week  after  her  delivery,  and  dissection 
proved  the  disease  to  have  acquired  the  aggravated  extent  above  described.  In  the  other  case 
the  os  uteri  was  but  partially  destroyed;  the  remainder  was  thickly  studded  with  schirrhous 
tubercles.  The  patient  was  worn  down  to  the  lowest  ebb  of  life,  and, — to  lull  the  acuteness 
of  her  sufferings, — had  been  in  the  habit  for  many  weeks  of  taking  two  ounces  of  laudanum 
daily.  I was  summoned  by  the  midwife  soon  after  the  commencement  of  labour,  and  on  my 
arrival  I found  that  death  had  just  taken  place.  There  were  present  unequivocal  proofs  that 
the  child  was  not  alive,  and  it  was  therefore  useless  to  extract  it  then.  On  opening  the  body 
next  day,  the  os  uteri  was  found  dilated  to  about  the  diameter  of  half  a crown,  partially 
ulcerated,  the  principal  portion  thickened,  and  exceedingly  indurated.  The  membranes  were 
ruptured , and  although  so  short  a time  had  elapsed  from  the  commencement  of  uterine  con- 
tractions, the  patient  had  evidently  sunk  exhausted. 

The  lady  who  was  the  subject  of  the  cauliflower  excrescence  had  borne  one  living  child 
seven  years  before  the  time  I speak  of;  and  my  father  had  been  attending  her  for  nearly  two 
years  for  the  uterine  affection,  during  which  she  had  once  miscarried.  She  became  pregnant 
a second  time  while  labouring  under  the  disease ; abortion  was  threatened,  but  was  with  care 
averted.  The  membranes  broke  early  on  the  morning  of  Sunday,  May  26th,  1828,  and  ute- 
rine action  camo  on  at  noon ; when  my  father  was  called,  he  found  the  os  uteri  would  just 
admit  the  tip  of  the  finger.  The  pains  continued  strong  all  day,  with  scarcely  any  increase 
in  dilatation;  and  at  night  an  opiate  was  given,  which  procured  an  intermission  of  suffering, 
but  no  sleep.  The  process  of  dilatation  went  on  very  slowly  through  Monday,  the  pains  con- 
tinuing regular  and  powerful.  I saw  her  for  the  first  time  at  half  past  eight  that  evening. 
The  os  uteri  was  then  dilated  to  the  size  of  a crown  ; and  from  its  whole  disc  a fungous  tumour 
sprang,  which  filled  a large  portion  of  the  vagina:  the  cervix  was  exceedingly  indurated  all 
round;  the  pains  were  very  strong,  and  the  vertex  was  being  forcibly  protruded  with  each 
return  of  uterine  action,  partially  through  the  undilated  and  unyielding  opening.  Still  the 
constitution  had  suffered  but  in  a slight  degree  from  the  protraction  of  the  labour,  although 
so  intensely  painful.  It  was  considered  that  it  would  be  premature  to  adopt  any  means  for 
delivery  just  then;  and  it  was  arranged  that  I should  remain  up  with  her  during  the  night. 
Very  little  alteration  was  perceptible  till  half  past  three  in  the  morning,  when,  under  the  in- 
fluence of  a violent  contraction,  she  suddenly  screamed  out  that  the  child  was  passing.  Being 
in  the  room  at  the  moment,  I instantly  made  an  examination,  and  found  the  head  had  escaped 
through  the  os  uteri,  and  was  occupying  the  pelvis : in  about  half  an  hour  it  was  expelled. 
The  child  was  alive,  and  is  ^so,  I believe,  still.  The  placenta  gave  no  trouble.  From  the 
rapidity  with  which  the  child’s  head  passed  through  the  os  uteri,  the  violent  shriek,  and  the 
rending  sensation  by  which  it  was  accompanied,  I have  little  doubt  that  a laceration  of  the 
organ  occurred;  although,  owing  to  the  confusion  of  parts  consequent  on  the  presence  of  the 
spongy  tumour,  I did  not  detect  any  breach  of  substance;  nor,  indeed,  was  I anxious  to  dis- 
turb the  tender  structures  by  making  a prolonged  and  very  minute  examination.  For  a 

24 


186 


LINGERING  LABOUR 


When  the  os  uteri  is  diseased,  we  shall  mostly  find  it  irregular,  knotty, 
and  very  painful  to  the  touch.  Symptoms  indicating  morbid  change  will 
probably  have  existed  prior  to  labour ; and — from  the  history  of  the  pre- 
vious sufferings  alone — there  can  be  little  difficulty  in  ascertaining  the 
nature  of  the  case.  If  it  be  not  much  dilated ; if  we  find  it  very  thick, 
tuberculated,  and  in  part  ulcerated  ; if  it  be  very  tender ; and  if  there  have 
been  previous  symptoms  of  uterine  affection, — such  as  acute  pains,  occa- 
sional and  irregular  eruptions  of  blood,  constant  or  very  frequent,  sanious, 
foetid,  acrid,  or  serous  discharges  from  the  vagina, — we  can  have  no  hesi- 
tation in  pronouncing  that  the  os  uteri  is  in  an  unhealthy  condition. 

Treatment. — Under  malignant  disease  of  the  mouth  of  the  womb,  it  is 
very  possible  that  a natural  termination  may  occur,  as  in  two  of  the  cases 
I have  related  in  the  note.  It  would,  therefore,  be  proper  to  delay  the 
application  of  any  means  of  relief,  so  long  as  is  compatible  with  the  pa- 
tient’s immediate  welfare ; moderating,  at  the  same  time,  excessive  action 
by  opiates  taken  into  the  stomach,  or  exhibited  per  anum . Mostly,  the 
patient’s  system  will  have  been  too  much  depressed,  by  the  wasting  nature 
of  the  disease  to  allow  of  the  abstraction  of  blood  ; nor,  indeed,  could  we 
expect  bleeding  to  be  followed  by  relaxation  of  the  organ,  when  its  struc- 
ture is  thus  morbidly  affected.  Nevertheless,  we  must  affix  a limit  to  our 
passive  treatment ; for,  as  in  more  ordinary  cases,  a period  may  arrive,  be- 
yond which  we  cannot  trust  to  nature.  Should  we  observe,  then,  incipient 
symptoms  of  exhaustion ; should  the  pains  begin  to  flag  ; and  should  an 
increased  quickness  of  pulse,  a more  anxiously  dejected  countenance,  or 
distressing  attacks  of  vomiting,  indicate  impending  danger,  it  would  neces- 
sarily become  an  anxious  question,  what  means  should  be  adopted  in  order 
to  afford  relief.  Delivery  offers  the  only  chance  of  preserving  the  patient 
from  her  approaching  fate.  But,  under  the  undilated  state  of  the  os  uteri 
which  I am  supposing,  it  would  be  impossible  to  apply  the  forceps,  or  use 
any  other  means  compatible  at  the  same  time  with  the  child’s  existence,  1 
and  with  the  continuity  of  the  mother’s  structures.  We  have,  therefore, 
the  choice  only  of  either  delivering  by  instruments,  which  must  necessa- 
rily destroy  the  infant, — provided  it  be  at  the  moment  living, — perform- 
ing the  Caesarean  section,  or  dividing  the  diseased  part  to  a sufficient  ex- 
fortnight she  continued  in  imminent  hazard,  but  at  the  end  of  a month  was  able  to  leave  her 
room.  I was  in  almost  daily  attendance  on  this  lady  for  fourteen  months  after  her  delivery, 
when  she  sank,  worn  to  a skeleton  by  pain,  haemorrhage,  and  serous  discharges.  So  profuse 
was  the  exudation  of  that  peculiar  serous  discharge,  eminently^haracteristic  of  cauliflower 
excrescence  of  the  os  uteri,  that  for  some  time  before  her  death  she  was  compelled  to  use  three 
dozen  napkins  in  the  four  and-twenty  hours,  each  of  which  was  perfectly  saturated  with  moisture. 
This  discharge  was  for  the  most  part  untinged  with  any  colouring  particles;  but  occasionally 
it  possessed  the  whole  constituents  of  the  blood ; and  dangerous  flooding  at  different  times 
occurred. 


FROM  RIGIDITY  OF  THE  OS  UTERI. 


187 


tent  to  permit  the  child  to  pass.  I presume  the  abdominal  incision  would 
not  be  contemplated  if  the  pelvis  were  of  ordinary  capacity;  and  we  should, 
therefore,  be  driven  to  the  alternative  of  either  perforating  the  head,  or 
making  a division  of  the  mouth  and  neck  of  the  womb  itself.  Considering, 
then,  that  the  woman  labours  under  a disease  which  must  terminate  in 
death, — and  that  probably  at  no  very  distant  period ; — that  the  os  uteri 
would  most  likely  be  torn  in  our  attempts  at  extraction ; that  the  incision 
would  not  necessarily  be  followed  by  fatal  consequences, — whilst  at  the 
same  time,  after  perforation  of  the  head,  the  child  must  certainly  be  born 
lifeless, — I should  prefer  operating  on  the  os  uteri,  unless,  indeed,  there 
were  present  tl  e most  unequivocal  signs  of  the  child’s  death:  and  I should 
even  hope  for  the  patient’s  survival  for  some  time,  being  cheered  by  the 
result  of  the  last  case  detailed  in  the  note,  in  which  I have  not  the  slightest 
doubt  that  a laceration  occurred. 

Common  rigidity. — The  rigidity  usually  met  with,  however,  is  inde- 
pendent of  diseased  structure,  and  is  known  by  the  os  uteri  being  hard, 
firm,  and  only  in  a slight  degree  painful — by  its  resisting  the  dilating  pow- 
ers of  the  membranes,  or  foetal  head — and  by  our  not  being  able  to  make 
any  imppression  on  its  edge  by  the  finger.  It  is  not  likely  that  we  can 
mistake  a case  of  rigidity  of  the  os  uteri  for  one  in  a more  natural  state. 
It  must  be  recollected,  however,  that  rigidity  of  the  soft  parts  may  co-exist 
with  a deformity  of  pelvis;  and  that  each  of  these  causes  may,  at  one  and 
the  same  time,  tend  in  some  degree  to  retard  the  process  of  labour. 

Treatment — Under  this  simple  rigidity  of  the  os  uteri,  it  is  our  duty, 
if  possible,  to  produce  a relaxation  in  the  organ ; and  we  are  possessed  of 
some  means  which  have  been  esteemed  highly  efficacious.  Observing 
how  supple  and  distensible  the  os  uteri  becomes,  and  how  readily  it  usually 
dilates  under  haemorrhage,  bleeding  has  very  generally  been  adopted  to 
effect  this  object.  This  is  certainly  a powerful,  but  by  no  means  entirely 
a safe  agent ; and,  unless  used  with  much  judgment,  is  likely  to  be  pro- 
ductive of  serious  evil.  The  great  objection  that  attaches  to  bleeding  at 
the  commencement  of  labour,  is,  that  there  must  necessarily  be  a certain 
quantity  of  blood  lost  after  the  child  is  born.  We  are  in  perfect  ignorance 
how  much  that  may  amount  to ; and  it  would  be  wanton  to  take  blood 
from  the  arm  without  grave  occasion,  when  the  few  ounces  we  may 
voluntarily  abstract, — had  they  been  preserved  in  the  woman’s  system, — 
might  have  turned  the  vacillating  beam  of  life  in  her  favour,  and  snatched 
her  from  impending  freath.  This,  however,  is  but  a remote*,  though  pro- 
bable, danger;  and  it  becomes  a question,  whether  we  ought  to  take  into 
account  a remote  probability,  when  weighed  against  a state  of  actual  and 
existing  difficulty.  My  father*  has  always  used  the  lancet  with  caution 

* See  Practical  Observations  in  Midwifery,  Part  I.  p.  231. 


188 


LINGERING  LABOUR 


under  the  first  stage  of  labour,  in  consequence  of  the  risk  of  flooding  after- 
wards ; and  I,  in  conformity  with  his  views,  adopting  his  sentiments,  and 
relying  greatly  on  his  practical  experience,  seldom  direct  bleeding  in  the 
first  stage  of  labour,  for  the  purpose,  simply,  of  overcoming  rigidity. 
There  are  about  two  thousand  three  hundred  women,  in  one  charity,  annu- 
ally delivered  under  my  immediate  superintendence ; these  patients’  labours 
are  not  of  more  than  an  average  length,  and  there  are  actually  fewer 
deaths  among  them  than  we  meet  with  in  the  higher  circles,  relatively  to 
the  amount  of  cases.  Of  this  number  I scarcely  bleed  one  under  labour, 
unless  the  os  uteri  be  so  painful  as  to  indicate  an  inflammatory  condition, 
or  there  be  evidences  of  undue  determination  of  blood  to  the  brain,  or 
symptoms  of  congestion  or  inflammation  of  some  other  viscus.  At  the 
same  time  it  is  but  fair  to  state  that  my  father,  although  he  is  adverse  to 
indiscriminate  bleeding  in  all  cases  of  rigidity  of  the  os  uteri,  considers  it 
sometimes  useful  to  soften  and  relax  that  organ ; that  Merriman* * * §  speaks 
with  praise  of  this  means  occasionally ; that  Deweesf  thinks  it  certain  and 
never  failing  in  its  effects ; Blundell, J Burns, § and  other  eminent  practi- 
tioners recommend  it ; and  Hamilton||  used  to  assure  his  class  that  he 
could  always  relax  the  os  uteri  by  bleeding;  and  that  he  never  allowed 
the  first  stage  of  labour  to  continue  longer  than  twelve  or  fourteen  hours, 
so  completely  had  he  the  process  under  his  control ; he  stated,  also,  that 
he  never  had  had  a patient  in  labour  more  than  twenty-four  hours,  except 
where  disproportion  existed,  since  he  began  this  practice.  There  is  cer- 
tainly no  doubt  that  the  robust  constitutions  of  the  northern  females  bear 
depletion  better  than  the  comparatively  weak  system  of  this  metropolis. 
This  observation  also  holds  good  in  regard  to  the  country : and  those  who 
are  engaged  amongst  a race  of  peasants  can  no  doubt  have  recourse  to 
bleeding  more  frequently  with  advantage,  than  others  can  dare  to  do  who 
are  located  among  a population  enervated  by  luxury,  or  debilitated  by  the 
want  of  wholesome  air,  food,  and  exercise. 

With  regard  to  bleeding,  then,  as  a means  of  relaxing  the  os  uteri,  I 
look  upon  it  as  powerful,  but  not  devoid  of  danger:  to  do  good,  it  must  be 
carried  far  enough  to  make  an  impression  on  the  general  system ; for  it  is 
idle  to  expect  advantage  will  be  derived  from  it,  unless  syncope,  or  at  any 
rate  a degree  of  faintness,  be  produced.  But  there  are  some  constitutions 

* Synopsis,  p.  29. 

t Essay  on  Facilitating-  Cases  of  Difficult  Parturition,  p.  98.  • 

t Obstetricy,  by  Castle,  p.  601. 

§ Principles  of  Midwifery.  Fifth  Edition,  p.  411. 

H MS.  Lectures,  1821.  See  also  Practical  Observations,  p.  137,  where  bleeding  is  recom- 
mended; and  p.  120,  where  the  necessity  of  securing  the  termination  of  the  first  stage  within 
the  specified  time  is  insisted  on. 


FROM  RIGIDITY  OF  THE  OS  UTERI. 


189 


which  bear  the  loss  of  blood  so  ill,  as  to  preclude  the  use  of  the  lancet 
entirely ; and  yet  in  such  we  may  possibly  meet  with  preternatural  rigidity. 
Even  the  warmest  advocates*  for  the  depleting  system  acknowledge  this 
to  be  the  case ; and  other  measures  have  consequently  been  had  recourse 
to  with  the  same  view. 

As  second  in  importance,  rank  opiate  enemata.  Opium,  whether  exhi- 
bited by  the  mouth,  or  in  injection, — provided  it  be  used  in  sufficient  quan- 
tity,— will  suspend  uterine  action,  as  well  as  relieve  muscular  spasm.  If 
the  contractions  then  are  not  powerful,  it  would  be  wrong  to  administer 
it.  Opium  is  found  of  incalculable  benefit  in  removing  false  pains,  and  is 
eminently  useful  in  those  cases  where  the  membranes  have  ruptured  early 
— where  the  uterus  is  acting  strongly  and  powerfully — where  it  is  urging 
the  head  of  the  child  against  its  undilated  mouth ; causing  excessive  agony; 
inducing  irritability,  fever,  and  nervous  excitement ; and  producing  no 
effect  equivalent  to  the  suffering  endured.  In  such  a case,  if  sleep  can  be 
obtained,  an  opportunity  of  recovery  is  afforded  to  the  system ; and  the 
woman  gains  strength  to  enable  her  to  bear  up  against  the  fatigue  neces- 
sarily attendant  on  such  great  exertion ; besides  which,  during  the  time  of 
inaction  a favourable  change  may  have  taken  place  in  the  os  uteri,  pre- 
disposing it  to  dilate  more  kindly  when  the  pains  return.  On  both  these 
accounts,  then,  opiate  injections  are  useful  when  the  pains  are  violent  and 
irritating,  and  not  producing  advantage  equivalent  to  the  suffering  they 
bring  with  them ; they  procure  rest  and  ease  for  a certain  period ; and,  in 
the  interval  of  action,  they  afford  an  opportunity  to  the  os  uteri  to  take  on 
itself  a more  kind  and  favourable  state.  I am  perfectly  satisfied  that 
opium  possesses  no  positive  power  to  relax  a rigid  os  uteri, f and  that  its 
virtues  are  entirely  centred  in  its  capability  of  moderating  excessive 
action.  The  danger  of  opiates  exhibited  under  labour  is,  that  the  uterine 
contractions  may  be  so  entirely  removed  through  their  ageney,  as  never 
again  to  be  established ; and  thus  the  case  may  be  converted  into  one 
requiring  the  use  of  instruments — perhaps  even  of  a destructive  kind. 

An  infusion  of  tobacco,  in  enema,  has  also  been  suggested  in  rigiditv : 
and  DeweesJ  has  related  a case  in  which  two  clysters  were  injected,  with 
the  view  of  relaxing  a vaginal  cicatrix,  an  interval  of  an  hour  and  a half 
intervening  between  their  administration;  but  the  alarming  symptoms 
which  supervened,  prove  the  danger  attendant  on  their  use.  This  herb  is 
very  efficacious  in  reducing  irregular  spasm,  and  relaxing  muscular  fibre; 

* Hamilton’s  Observations,  p.  137. 

t Dewees,  in  his  Essay  on  Facilitating  certain  Cases  of  Difficult  Parturition,  p.  84.  advances 
the  same  opinion  regarding  the  inefficacy  of  opium  as  a relaxing  agent. 

t System  of  Midwifery,  p.  379. 


190 


LINGERING  LABOUR 


but  independently  of  its  dangerous  character,  it  is  of  no  avail  in  rendering 
the  os  uteri  more  supple : nor,  indeed,  should  we,  cl  priori , expect  such  an 
effect  from  its  application  ; for  the  difficulty  experienced  does  not  arise 
from  accidental  spasm,  or  irregular  fibrous  contraction ; but  depends  upon 
an  originally  firm,  hard,  rigid,  and  unyielding  texture. 

Common  domestic  clysters  are  most  useful  and  valuable  assistants 
under  all  cases  of  rigidity,  both  of  the  os  uteri  and  vagina.  They  are 
serviceable  by  clearing  the  bowels,  by  acting  as  an  internal  fomentation, 
and  also  by  amusing  the  patient’s  mind.  By  having  recourse  to  such 
harmless  means,  we  give  her  reason  to  think  that  she  is  not  neglected,  but 
that  all  is  being  done  for  her  relief  which  art  can  accomplish : and  thus 
both  hope  and  confidence  are  inspired,  and  time  is  also  gained  for  a full 
and  fair  trial  of  nature’s  powers;  which  negative  virtue,  indeed,  is  of 
equal,  or  perhaps  greater  advantage,  than  any  of  the  more  positively 
useful  attributes  of  these  applications. 

Substances  have  been  applied  to  the  mouth  of  the  womb  itself,  with  a 
view  to  relax  it : and  belladonna  has  been  recommended  for  this  purpose  ; 
in  London,  by  Conquest;*  and  in  France,  by  Chaussier,  Velpeau,  and  La 
Chapelle ; but  this  practice  has  not  met  with  the  general  sanction  of  the 
profession  in  this  country.  It  is  recommended  that  one  or  two  drachms 
of  the  extract  undiluted  be  rubbed  on  the  os  uteri ; or  it  may  be  mixed 
with  lard  in  various  proportions. 

The  knowledge  of  the  extraordinary  powders  which  this  drug  possesses 
in  relieving  pain  by  paralyzing  nervous  excitability,  and  overcoming  tonic 
spasm,  led  to  its  employment  in  this  species  of  agonizing  labour ; but  it 
seems  to  have  no  effect  in  producing  relaxation  of  the  os  uteri;  and  if  no 
good  result  from  its  use,  it  must  be  injurious ; — not  in  consequence  of  the 
poisonous  quality  resident  in  the  drug  itself,  but  from  the  friction  which  is 
necessary  for  its  efficient  application.  The  mucus  that  naturally  lubri- 
cates the  part  must  be  wiped  away,  and  this  irritation  must  predispose  the 
tender  organ  to  take  upon  itself  inflammatory  action. 

It  is  the  custom,  also,  in  France,  to  inject  mucilaginous  fluids,  as 
recommended  by  Gardien,f  and  wrarm  oil,  into  the  vagina,  for  the  purpose 
of  softening  the  os  uteri,  and  giving  an  extra  degree  of  lubrication.  I do 
not  see  the  slightest  objection  to  this  practice,  and  in  some  instances  it 
may  be  desirable  and  beneficial.  Two  or  three  syringes  full  might  be 
thrown  up  once  in  every  hour. 

The  warm  bath  has  been  suggested,  and  a trial  made  of  its  effect,  by 


* Conquest’s  Outlines,  6th  edit.  p.  82. 
t Traite  d’  Accouchemens,  vol.  ii.  p.  271,  1807. 


FROM  RIGIDITY  OF  THE  OS  UTERI. 


191 


Dewees  ;*  but  it  is  inconvenient  in  its  use  ; it  is  not  generally  at  hand  ; it 
tends  to  weaken  the  system,  and  is  of  no  service  in  relaxing  the  part : it 
cannot,  however,  do  much  injury,  unless  indeed  it  may  produce  haemor- 
rhage, (as  it  seemed  to  have  done  in  one  of  the  cases  cited  by  Dewees,) 
and  perhaps,  in  some  very  rare  instances,  it  might  be  of  benefit,  especially 
if  there  were  preternatural  heat  and  dryness  of  the  skin.  External 
warmth  applied  to  the  vulva,  as  in  cases  of  rigidity  of  the  vagina  and 
perineum,  will  occasionally  be  desirable;  but  its  relaxing  effect  on  the  os 
uteri  is  very  questionable. 

Under  a state  of  preternatural  rigidity  of  the  os  uteri,  it  not  unfre- 
quently  happens  that,  without  any  apparent  cause,  and  independently  of 
any  means  being  used,  sudden  relaxation  takes  place ; and  from  that  time 
the  labour  progresses  with  much  greater  rapidity.  This  favourable  altera- 
tion in  the  condition  of  the  organ  is  generally  accompanied  by  sickness ; 
and  I always  hail  an  attack  of  vomiting  under  such  circumstances,  pro- 
vided there  be  no  symptoms  of  exhaustion  present,  as  the  harbinger  of  a 
fortunate  change.  Emetics  have  been  recommended  for  the  purpose  of 
facilitating  the  dilatation  of  the  uterine  mouth,  under  the  erroneous  idea 
that  the  vomiting  was  the  cause  of  the  softening  observed  ; but  artificial 
vomiting,  induced  with  this  view,  has  disappointed  the  expectations  of 
its  advocates.f  Antimony,  nevertheless,  in  doses  sufficient  to  keep  up  a 
feeling  of  nausea,  has  been  exhibited  in  these  cases  with  marked  advan- 
tage. 

Under  rigidity  of  the  os  uteri,  the  forceps  can  never  be  available. 
Unless  this  organ,  indeed,  is  entirely,  or  almost  entirely  dilated,  neither 
the  long  nor  the  short  forceps  can  be  used.  I am  not  prepared  to  assert, 
that  in  some  rare  instances  of  rigidity  the  head  may  not  require  to  be 
opened : it  is  seldom,  however,  that  such  an  extreme  case'  exists ; for  in 
time  the  organ  usually  gives  way.  When  this  condition  of  the  os  uteri 
is  the  sole  cause  of  delay,  we  should  wait  until  the  last  moment  consistent 


* Essay  on  Difficult  Parturition,  p.  87. 

t Riverius,  two  centuries  ago,  remarked  on  the  practice  of  giving  emetics  to  facilitate 
uterine  dilatation;  and  Lowder  said,  “ he  had  often  known  spontaneous  vomiting  do  good,  but 
had  seldom  found  benefit  from  the  exhibition  of  emetics,  though  he  had  frequently  seen  them 
used.”  The  most  disgusting  substances  in  nature  have  been  advised,  at  different  times,  to 
expedite  parturition.  Thus  Hartman  (Opera  folio,  p.  72)  tell  us  “ Apud  pauperes  vidi  saepS 
partum  difficilem  solvi  haustu  urinae  mariti.  Sic  stercus  equinum  in  vino  expressum  et  per- 
colatum,  subitb  foetum  et  secundas  expellit.”  A midwife  also,  named  Sarah  Stone,  who 
published  some  cases  in  1737,  gives  several  instances  in  which  women  in  labour  were  made 
to  drink  their  husbands’ urine.  Merriman — Synopsis,  p.  30 — who  quotes  these  passages — 
remarks,  “ If  such  horrible  messes  were  ever  serviceable,  it  was  probably  by  inducing  nausea 
and  vomiting.”  Perhaps  the  effect  on  the  mind,  arising  from  the  confidence  with  which  they 
were  advised,  might  also  have  had  some  influence. 


192 


LINGERING  LABOUR 


with  the  probability  of  the  woman’s  ultimate  recovery,  before  we  think 
of  destroying  the  child’s  life. 

Generally,  in  cases  where  the  os  uteri  is  rigid,  it  is  found  high,  at  the 
brim  of  the  pelvis,  or  in  its  natural  situation ; but  at  other  times  the  head 
of  the  child  has  descended  into  the  pelvic  cavity,  covered  by  the  thin 
expanded  cervix ; and  the  mouth  of  the  womb  is  comparatively  low, 
looking  back  towards  the  coccyx  or  sacrum.  Such  a case  may  be  the 
occasion  of  much  error  and  disappointment,  unless  it  be  clearly  detected: 
for,  on  passing  the  finger  for  the  purpose  of  making  an  examination,  the 
tumour  caused  by  the  head  will  be  distinctly  felt  occupying  the  pelvic 
cavity ; and  if  the  examination  be  carelessly  conducted,  or  the  possibility 
of  the  occurrence  did  not  offer  itself  to  our  mind,  we  might  suppose  that 
the  child  would  be  born  immediately.  If  we  form  an  opinion  to  that 
effect,  however,  in  such  a case,  we  shall  be  greatly  deceived ; for  many 
hours  of  wearying  pain  must  be  experienced  before  the  os  uteri  will  dilate 
in  a sufficient  degree  to  allow  the  transit  of  the  head.  The  sensation  com- 
municated to  the  finger  by  the  tumour  itself  will  sufficiently  indicate  the 
nature  of  the  case.  Instead  of  feeling  the  denuded  hairy  scalp,  we  detect 
a smooth,  polished  surface;  sensible — perhaps  acutely  so — to  the  touch; 
neither  suture  nor  fontanelle  will  be  distinguishable ; and,  on  carrying  the 
finger  back  towards  the  sacrum  or  coccyx,  we  shall  find  the  os  uteri 
opened  not  more  than  to  the  size  of  a sixpence  or  shilling ; and  through 
its  orifice  the  head  will  be  clearly  perceptible.  From  the  sensibility  of  the 
structure,  then  against  which  the  finger  is  pressed,  the  smoothness  of  its 
surface,  the  indistinctness  of  the  sutures  or  fontanelles,  the  absence  of 
hair,  and  the  aperture  distinguishable  at  the  posterior  part  of  the  tumour, 
that  fills  the  pelvis,  we  may  know  that  the  head  has  not  cleared  the  uterus, 
but  that  it  has  come  down  covered  by  the  thinned  neck. 

Rigidity  of  the  Vagina  and  Perineum. — The  vagina  and  perineum  are 
sometimes  so  rigid  as  to  prevent  the  exit  of  the  child ; with  this  there  often 
exists  also  rigidity  of  the  sacro-ischiatic  and  coccygeal  ligaments,  which 
adds  much  to  the  difficulty  of  the  case.  ; 

This  state  much  more  usually  occurs  with  first  than  subsequent  chil- 
dren ; indeed,  simple  rigidity  of  the  vagina  and  perineum,  when  the  patient 
has  borne  a family,  is  very  rare.  Sometimes,  rigidity  of  these  organs 
singly  may  be  the  cause  of  delay ; but  it  is  much  more  frequently  combined 
with  the  same  condition  of  the  os  uteri. 

Diagnosis. — There  is  little  difficulty  in  detecting  the  existence  of  rigidity 
in  the  vagina  and  perineum  ; we  may  ascertain  it  by  the  firmness,  dryness, 
narrowness,  and  want  of  distensibility,  which  characterize  the  state.  The 
rigidity  will  sometimes  exist  to  such  an  extent,  that  two  fingers  cannot  be 
massed  without  difficulty  up  to  the  os  uteri ; and  yet,  even  under  this  aggra- 


FROM  RIGIDITY  OF  THE  OS  UTERI. 


193 


vated  condition,  the  parts  will  most  probably,  in  process  of  time,  become 
moistened,  softened,  and  distensible ; they  will  eventually  dilate,  and  the 
case  may  be  naturally  terminated.  When  this  unfavourable  constitu- 
tion of  the  vagina  exists,  if  the  os  uteri  be  widely  open,  and  the  pains  be 
strong,  great  pressure  will  be  exerted  on  the  parts  within  the  pelvis,  and 
all  the  injurious  effects  of  contusion  and  strangulated  vessels  may  be  emi- 
nently dreaded. 

Treatment . — Here,  also,  it  is  our  duty  to  endeavour  to  relax  the  rigid 
structures ; with  this  intention,  bleeding  has  been  had  recourse  to,  as  libe- 
rally and  almost  as  universally  as  under  rigidity  of  the  os  uteri  itself;  but 
bleeding  certainly  does  not  possess  the  same  power  in  this  as  in  the  case 
last  under  consideration.  I am  inclined  to  limit  the  use  of  the  lancet  to 
those  instances  where  the  rigidity  is  combined  with  heat,  tumefaction, 
unusual  tenderness,  and  unnatural  dryness, — symptoms  which  denote  that 
injurious  pressure  has  taken  place,  and  that  inflammatory  action  has  com- 
menced. Opiate  injections  have  also  been  generally  adopted ; but  they 
seem  neither  of  so  much  avail  as  in  rigidity  of  the  os  uteri,  nor  indeed  are 
they  so  much  called  for ; because  there  is  not  such  distressing  pain  expe- 
rienced as  when  the  head  is  pressing  strongly  against  the  hard,  undilated 
os  uteri ; but  if  the  uterine  contractions  are  exceedingly  violent,  an  opiate 
enema  may  prevent  laceration.  Simple  domestic  clysters  are  also  of  essen- 
tial service,  and  may  be  used  in  any  case. 

Warm  fomentations  are  sometimes  of  great  advantage.  Flannels  may 
be  dipped  in  hot  water,  or  a decoction  of  poppy-heads,  and  applied  to  the 
labia  externa  and  perineum.  They  may  be  continued,  with  little  inter- 
mission, for  four  or  six  hours  at  a time.  The  warmth  is  grateful  to  the 
patient,  and  the  relaxing  influence  has  sometimes  appeared  sufficiently 
evident.  Another  means  of  applying  warmth  externally  is  by  desiring  the 
patient  to  sit  over  the  steam  of  hot  water,  provided  she  can  maintain  the 
sendentary  position  without  great  inconvenience  : one  principal  use,  how- 
ever, of  these  latter  means  is  to  gain  time,  so  as  to  allow  the  natural 
powers  an  opportunity  of  exerting  themselves  efficiently,  and  at  the  same 
time  to  convince  the  woman  that  our  mind  is  directed  towards  affording 
her  relief.  Warm  oil  might  be  injected  into  the  vagina,  if  the  parts  were 
dry,  and  harsh,  and  hot ; and  if  the  head  were  not  lying  too  low  to  prevent 
the  introduction  of  the  fluid  : but,  generally,  this  will  not  be  practicable; 
and  lard  will  be  found  a more  easy  and  useful  application.  The  external 
parts  may  be  lubricated  by  a little  occasionally  smeared  over  them  ; and 
a small  portion  may  be  carried  as  high  as  possible  within  the  vagina,  and 
permitted  to  melt  there.  I have  often  found  this  cooling  application  very 
grateful  to  the  patient ; and  have  fancied  that,  at  the  same  time,  it  has 
tended  to  produce  relaxation.  1 would,  however,  caution  the  student 
25 


194 


LINGERING  LABOUR 


strongly  against  unnecessary,  meddlesome  interference  : all  rubbing  must 
be  avoided ; and  if  this  lubrication  is  used  at  all,  it  must  be  in  the  tenderest 
and  gdntlest  manner ; for  much  more  injury  will  accrue  from  denuding 
the  parts  of  their  natural  mucus,  than  good,  from  the  artificial  moisture 
which  the  unctuous  substance  affords.* 

It  is  impossible  to  paint  in  too  vivid  terms  the  dangers  that  may  follow 
the  use  of  the  ergot  of  rye  in  the  cases  now  treated  of.  There  is  scarcely 
an  accident  to  which  the  woman  in  labour  is  exposed,  but  may  be  induced 
by  its  injudicious  administration.  In  the  two  subjoined  instances  I attri- 
buted the  mischief  that  ensued  entirely  to  its  employment.^ 

* Merriman  (Synopsis,  p.  29,)  says,  the  best  method  of  using  unctuous  applications  in  these 
cases  is  to  introduce  a ball  of  fine  tallow,  about  the  size  of  a nutmeg,  high  up  by  the  side  of 
the  head,  and  leave  it  to  dissolve  and  diffuse  itself  over  the  vagina.  Thatcher  (MS.  Lect. 
1820)  prefers  a liberal  application  of  fresh  butter,- which,  as  being  of  greater  consistence  than 
lard,  is  more  manageable. 

f Late  one  evening,  in  the  year  1829,  after  a very  fatiguing  day,  I received  a message 
from  a midwife,  requesting  my  attendance  on  a patient  in  labour  of  her  tenth  child.  I was 
informed  that  the  membranes  had  been  ruptured  more  than  twenty-four  hours, — that  the 
breech  was  in  the  pelvis, — that  the  uterus  had  acted  very  feebly  from  the  commencement  of 
the  labour,  but  particularly  so  since  the  discharge  of  the  waters,  and  that  the  whole  cause  of 
delay  seemed  to  be  an  insufficiency  of  pains.  I directed  an  old  and  intelligent  pupil,  at  that 
time  resident  in  my  house,  to  accompany  the  messenger,  to  take  with  him  some  ergot,  and  to 
exhibit  it,  if  he  thought  the  case  fitted  for  its  use.  He  gave  half  a drachm,  infused,  imme- 
diately, and  another  dose  of  equal  strength  half  an  hour  after.  Ten  minutes  had  scarcely 
elapsed  from  the  administration  of  the  second  quantity,  when  the  uterus  began  to  act  most 
powerfully  ; in  ten  minutes  more  the  child  was  born, — wholly  without  artificial  assistance, — 
and  the  placenta  passed  quickly,  with  very  slight  discharge.  He  returned  quite  delighted 
with  the  powers  of  the  drug.  Early  in  the  morning,  however,  I received  a second  summons, 
stating  that  the  patient  had  experienced  violent  pains  all  night,  had  lost  a large  quantity  of 
blood,  and  appeared  very  ill..  On  my  arrival  I found  her  recovering  from  a state  of  faintness, 
and  complaining  of  acute  suffering  at  the  lower  part  of  the  person-  She  had  sustained  a 
copious  discharge  of  blood,  as  was  evidenced  by  the  appearance  of  the  room ; for  a large  quan-  i 
tity  had  soaked  through  the  bed,  and  lay  in  a pool  upon  the  floor.  On  placing  my  hand  on 
the  uterus,  I found  it  exceedingly  well  contracted,  hard,  and  by  no  means  tender  ; and  it  was ' 
plain  that  the  haemorrhage  had  not  proceeded  frym  that  organ.  Examining  farther,  I disco- 
vered that  the  right  labium  was  very  much  distended,  and  painful  on  pressure  being  applied. 
There  was,  indeed,  a longitudinal  laceration  just  within,  extending  the  whole  length  of  the 
labium ; and  the  cellular  structure  of  the  part  was  filled  with  a very  firm  coagulum.  On  the 
removal  of  the  clot,  an  oozing  of  arterial  blood  was  perceptible,  which,  however,  was  restrained 
by  the  use  of  pressure  and  other  means.  An  opiate  procured  sleep.  In  a few  days  healthy 
granulations  made  their  appearance;  in  little  more  than  a fortnight  the  cavity  was  quite  filled 
up,  and  a permanent  cicatrix  of  about  two  inches  in  length  showed  the  situation  and  extent  of 
the  injury. 

At  a later  date,  I was  called,  in  consultation,  to  a case  in  which  the  uterus  had  ruptured 
after  the  exhibition  of  a dose  of  ergot.  The  accident  might  certainly  have  occurred  had  this 
drug  not  have  been  given,  but  I had  good  reason  to  believe  the  medicine  had  mainly  contri- 
buted to  the  lamentable  catastrophe ; there  was  a slightly  distorted  pelvis.  I have  known 
also  some  other  cases  of  a similar  nature. — Such  are  the  dangers  likely  to  arise  from  the 
administration  of  the  ergot  in  cases  unfitted  for  its  use. 


FROM  OBLIQUITY  OF  THE  OS  UTERI.  195 

* * 4 */*'• . 

It  is  a very  common  practice  with  attendants,  in  lingering  labour,  to 
excite  the  patient  to  take  stimulants,  under  the  idea  that  her  strength  must 
be  very  much  exhausted,  and  that  some  extraordinary  means  are  required 
to  sustain  her.  No  custom  can  be  more  injudicious.  Even  in  common 
cases  great  danger  must  spring  from  its  adoption ; but  it  is  particularly  to 
be  deprecated  where  rigidity  is  the  cause  of  delay : for,  by  increasing  the 
power  of  the  uterine  contractions,  stimulants  will  have  the  effect  of  forcing 
the  head  strongly  against  structures  unprepared  to  admit  it,  and, — inde- 
pendently of  inducing  fever  and  premature  exhaustion, — may  occasion 
laceration  of  the  organs  which  refuse  to  yield.  For  the  same  reasons,  all 
voluntary  efforts  on  the  part  of  the  patient  must  be  restrained  as  much  as 
possible;  and — if  from  ignorance  or  obstinacy,  her  officious  friends  per- 
sist in  urg'ing  her  to  call  those  powers  which  are  under  her  control,  to  the 
assistance  of  the  uterine  energies, — the  injurious  tendency  of  this  advice 
must  be  candidly  and  plainly  pointed  out. 

When  the  head  presses  on  the  perineum,  the  extended  structures  must 
be  supported  constantly  and  anxiously,  lest  they  should  rupture  : the  more 
rigid  the  parts  are,  indeed,  the  greater  must  be  our  assiduity:  and  this  is 
occasionally  a most  distressing  and  irksome  duty.* 

5th.  Cicatrix  in  the  Vagina. — A cicatrix  in  the  vagina,  the  result  of 
sloughing  under  a previous  protracted  labour,  will  occasionally  be  found  to 
impede  delivery.  When  the  healing  process  is  established  in  the  ulcer, 
which  is  left  on  the  separation  of  the  slough,  a puckering  of  the  vaginal 
membrane  takes  place ; the  surface  is  diminished  in  extent,  and  conse- 
quently the  diameter  of  the  canal  is  lessened.  In  proportion  to  the  extent 
of  the  slough,  in  general  will  the  difficulty  be.  The  history  of  the  case 
will  be  in  itself  almost  sufficient  to  enable  us  to  judge  of  the  nature  of  the 
impediment.  We  shall  find  that  the  patient  will  have  suffered  one  or 
more  lingering,  and  probably  instrumental  labours;  that  symptoms  of 
inflammation  of  the  vagina  occurred  after  one  of  the  deliveries,  and  that 
her  convalescence  was  protracted.  On  making  an  examination,  we  shall 
detect,  at  some  portion  of  the  vaginal  surface,  a fibrous,  unyielding  band, 
preventing  the  passage  of  the  head.  The  edge  of  this  band  may  be  as 
thin  as  paper,  or  it  may  run  up  for  a quarter  or  half  an  inch  in  length, 
narrowing  the  canal  to  that  extent  longitudinally. 

Treatment . — It  is  very  possible  that  nature  unaided  will  overcome  the 
difficulty  offered  by  a cicatrix  in  the  vagina ; and  it  would,  therefore, 
become  our  duty  to  wait  a moderate  time,  that  we  may  give  her  an 

* Hamilton  (Practical  Observations,  p.  155)  says  he  has  often  had  occasion  to  make  coun- 
ter-pressure from  five  to  nine  hours ; and  at  p.  120  he  states  that  he  once  supported  the  peri- 
neum, without  leaving  the  patient  for  a moment,  for  twelve  hours. 


196 


LINGERING  LABOUR 


opportunity  of  surmounting  the  impediment.  Either  relaxation  may 
occur  to  such  a degree  as  to  allow  the  child  to  pass,  or  the  fibrous  band 
may  lacerate  under  the  strength  of  the  contractile  powers.  Should  the 
desirable  softening,  however,  not  take  place, — rather  than  run  the  risk  of 
extensive  contusions,  by  the  continued  residence  of  the  head  in  the  pelvic 
cavity — rather  than  have  recourse  to  forcible  attempts  to  deliver  by  the 
forceps, — it  would  be  right  to  enlarge  the  passage  artificially.  Four  slight, 
incisions  may  be  made  into  the  edge  of  the  constricted  part : one  towards 
each  sacro-iliac  symphysis,  and  one  behind  each  groin,  avoiding  particu- 
larly the  neck  of  the  bladder,  the  rectum,  and  the  uterine  arteries  which 
run  up  from  below,  one  on  each  side  the  vagina.  If  four  incisions  be 
made,  the  least  snip  that  can  be  formed  will  usually  be  sufficient ; for  it  is 
more  than  probable  that  the  aperture  will  be  widened  by  laceration  : and 
I am  inclined  to  think  this  would  be  preferable  to  making  an  extensive 
cut,  because  of  the  danger  we  incur  of  wounding,  not  only  the  rectum  or 
bladder,  but  also  some  of  the  large  vessels  with  which  the  vagina  is  so 
liberally  supplied.  It  would  afterwards  becorpe  a subject  of  consideration, 
whether  the  case  should  be  left  to  the  natural  powers,  or  whether  instru- 
mental means  should  be  resorted  to,  to  terminate  the  labour.  The  answer 
to  such  a question  must  entirely  depend  upon  the  peculiar  circumstances 
attendant  on  each  case.  After  delivery,  when  the  healing  process  begins 
to  be  established,  care  must  be  taken  that  a diminution  in  the  capacity  of 
the  canal  to  any  considerable  extent  does  not  again  occur ; and  this  would 
be  best  prevented  by  the  introduction  of  a piece  of  sponge,  dipped  in  oil, 
to  act  as  a tent,  and  preserve  the  vaginal  parietes  distended.  This  should 
be  changed  two  or  three  times  a day,  and  its  use  persevered  in  for  some 
time. 

Notwithstanding  the  high  authority  of  Dr.  Dewees,  I should  by  no 
means  trust  implicitly  to  the  abstraction  of  blood,  for  the  purpose  of  pro- 
curing relaxation  of  the  cicatrized  and  constricted  membrane.  The 
American  practitioners,  indeed,  are  in  the  habit  of  carrying  depletion, 
with  this  intent,  to  a degree  which  we  seldom  hear  of  in  England. 
Dewees  has  given  three  cases,  in  which  he  attributes  the  relaxation  of  the 
cicatrix  entirely  to  this  means.  In  one  of  these  instances,  however, 
between  sixty-five  and  seventy  ounces  were  drawn  at  two  bleedings  ; and 
another  of  his  patients  lost  upwards  of  two  quarts  of  blood  at  one  opera- 
tion, through  the  agency  of  the  lancet,  after  a previous  bleeding  to  the 
amount  of  twelve  or  fourteen  ounces, — a quantity,  the  abstraction  of 
which  few  women  in  this  part  of  the  world  would  bear.* 

UNRurxuRED  hymen. — Impregnation  has  occasionally  been  effected 


System  of  Midwifery,  p.  376. 


FROM  OBLIQUITY  OF  THE  OS  UTERI. 


197 


although  the  hymen  has  never  been  broken;  and  if  this  membrane 
remained  entire  till  the  period  of  labour,  it  would  form  a greater  or  less 
impediment  to  the  passage  of  the  child.  I have  been  consulted  in  one 
case  of  this  description,  and  another  has  come  under  my  father’s  personal 
observation.  Such  a cause  of  protraction  must  of  course  be  met  with  in 
a first  labour ; and  by  this  circumstance  it  could  be  discriminated  from  a 
cicatrix,  the  result  of  previous  sloughing.  Its  situation  would  be  just  at 
the  vaginal  entrance,  and  its  form  would  also  assist  us  in  determining  its 
nature.  The  aperture  must  be  dilated,  if  possible,  by  mechanical  means ; 
and  if  that  cannot  be  effected,  the  case  must  be  treated  in  every  respect 
upon  the  principles  just  laid  down  for  the  management  of  a cicatrix. 

6th.  Obliquity  of  the  Os  Uteri. — The  last  cause  of  delay  attributable  to  the 
mother  is  obliquity  of  the  os  uteri ; and  this  has  been  much  insisted  on  by 
some  continental  writers.*  It  is  certainly  true,  that  when  a woman  has 
borne  a large  family,  the  abdominal  muscles  become  relaxed,  lose  their 
tone,  and  cease  to  afford  that  support  which  the  gravid  uterus  ought  to 
derive  from  them : the  abdomen  consequently  becomes  pendulous ; the 
axis  of  the  uterus,  in  respect  to  the  person,  is  changed ; its  fundus  is 
thrown  forwards,  and  its  mouth  is  directed  too  much  backwards  against 
the  sacrum.  The  upper  part  of  the  uterus  has  also  been  observed  to  fall 
to  the  right  or  left  side,  and  the  mouth  to  be  turned  towards  the  opposite 
ilium.  Under  such  circumstances,  we  are  recommended  to  place  the 
patient  either  on  her  back,  or  on  the  right  or  the  left  side,  as  circumstances 
may  require,  in  order  to  admit  of  the  body  and  fundus  of  the  uterus  gra- 
vitating in  the  proper  direction.  We  are  also  instructed  to  draw  the 
uterine  mouth  more  into  the  centre  of  the  pelvis,  by  the  fingers  hooked 
within  it.f 

As  far  as  the  change  of  the  woman’s  posture  is  concerned,  I can  have 
no  objection  to  the  treatment ; and  I would,  moreover,  endeavour  to 
retain  the  uterus  in  the  necessary  situation,  by  a bandage  girt  with  mode- 
rate pressure  round  the  person : but  I am  decidedly  opposed  to  any  forcible 
attempts  being  made  to  drag  the  os  uteri  into  a more  convenient  situation ; 
lest  it  should  be  lacerated  or  bruised,  or  excited  to  inflammatory  action, 
by  the  irritation  necessarily  attendant  on  our  endeavours : and  I have  at 

* Daventer  was  the  first  to  lay  great  stress  on  obliquity  of  the  os  uteri  as  being  a very 
frequent  cause  of  difficult  labour.  (Midwifery,  3rd  edit.  pp.  56,  234,  &c.)  The  same  idea  was 
taken  up  about  the  same  time  by  Pcu,  (Pratique  des  Accouchemens,  p.  582,  et  seq.)  and  has 
been  adopted  by  Levret,  (I’Art  des  Accouchemens,  par.  637,  &c.)  by  Roederer,  (Elem.  des 
Accouchemens,  par.  449,)  and,  in  a modified  degree,  by  Baudelocque,  (par.  272,  et  seq.)  and 
other  French  authors. 

t Baudelocque,  (par.  298,)  Velpeau,  (edit.  Brux.  p.  365,)  and  others,  recommend  that  the 
os  uteri  should  be  brought  over  the  centre  of  the  pelvic  brim  by  means  of  the  fingers. 


198 


LINGERING  LABOUR 


best  very  little  faith  in  obliquity  of  the  os  uteri  producing  serious  protrac- 
tion, unless  indeed  there  be  present  also  more  or  less  rigidity,  or  some 
disproportion  between  the  pelvis  and  head.* 

II.  Causes  referable  to  the  Ovum. 

IsL  Preternatural  toughness  of  the  membranes  is  by  no  means  a 
very  frequent  cause  of  lingering  labour ; nor  is  it  difficult  to  overcome, 
when  clearly  distinguished : it  is,  indeed,  by  far  more  common  for 
a premature  rupture  of  the  membranous  cyst  to  produce  a protrac- 
tion of  the  process;  since  the  passages  are  then  deprived  of  the  ad- 
vantage of  that  soft  dilating  medium,  which  it  offers  when  entire.  If, 
however,  the  membranes  be  exceedingly  strong,  as  occasionally  they 
are, — although  possessing  their  usual  thinness  and  pellucidity, — it  is  evi- 
dent that  the  very  circumstance  of  the  bag  remaining  whole  after  the  full 
dilatation  of  the  parts  is  effected,  will  necessarily  more  or  less  prolong  the 
labour ; since  the  ovum  must  either  pass  unbroken,  or  a greater  force  than 
ordinary  must  be  exerted  by  the  uterus  to  destroy  its  integrity.  It  is  not 
to  be  expected  that  the  ovum  will  be  expelled  whole,  provided  the  term 
of  gestation  be  nearly  perfected ; nor,  indeed,  is  such  an  event  desirable, 
because  of  the  dangers  which  must  accrue  both  to  the  mother  and  the 
foetus ; — to  the  mother,  in  consequence  of  the  great  probability  of  haemor- 
rhage from  the  sudden  emptying  of  the  uterine  cavity  of  all  its  contents  at 
once ; — to  the  foetus,  from  its  being  deprived  of  the  means  of  life  through 
the  placental  circulation,  before  it  can  enjoy  the  equivalent  advantage  of 
respiration. 

I have  already  laid  it  down  as  a principle,  that  in  ordinary  cases,  so  far 
from  desiring  the  early  rupture  of  the  membranes,  we  should  be  anxious 
to  preserve  them  as  long  as  possible ; — until,  indeed,  the  os  uteri  is  per- 
fectly opened,  the  vagina  distended,  and  they  have  protruded  somewhat 
externally.  As  soon,  however,  as  they  have  appeared  in  the  least  out- 
ward to  the  vulva,  we  may  suppose  that  all  the  advantage  which  can  be 
derived  from  them  has  been  gained;  and,  should  they  still  resist  the  power 
of  the  uterine  contractions,  we  may  conclude  that  their  preternatural 
toughness  is  retarding  the  exit  of  the  head. 

Treatment.— In  this  simple  case  it  is  only  necessary  to  perforate  the 
bag  with  the  finger-nail,  a pointed  quill,  or  a stilette : the  waters  will 
escape ; the  head  of  the  child  will  then  enter  the  pelvis,  if  it  has  not  pre- 
viously done  so ; and— provided  this  be  the  sole  cause  of  delay — the  dif- 
ficulty will  immediately  vanish. 


* See  William  Hunter’s  Anat.  of  Gravid  Ut.  p.  1C  ; Denman’s  Introduct,  to  Mid.  chap.  x. 
sect.  5,  art.  4 ; and  Davis’s  Principles  of  Obstetric  Med.  p.  979. 


« 


FROM  A DROPSICAL  HEAD. 


199 


2d.  Head  preter naturally  enlarged. — The  second  cause  referable  to 
the  ovum  is  a preternaturally  large  head,  either  from  healthy  formation, 
monstrosity,  or  disease.  It  has  been  already  stated,*  that  the  size  and 
weight,  of  infants  at  birth  vary  exceedingly ; — that  three  instances  are 
recorded,  where  the  child  weighed  considerably  above  sixteen  pounds ; 
and  we  may  naturally  conclude,  that  when  the  general  bulk  so  pro- 
digiously exceeds  the  common  average,  the  head  will  partake  of  the  exu- 
berant growth,  and  occasion  a proportionate  difficulty  under  labour. 

In  such  a case  it  is  probable  that  the  true  cause  of  protraction  will  not 
be  discovered  until  the  head  have  entered  the  pelvis,  or  engaged  some- 
what in  the  superior  strait.  But  its  mere  extraordinary  size  would  rot 
influence  our  treatment,  or  abrogate  the  general  rule — that  we  should 
desist  from  interfering  instrumentally,  until  symptoms  supervened  indica- 
tive of  distress,  and  requiring  relief. 

Rare  as  the  last  cause  of  protraction  must  necessarily  be,  it  is  still  more 
uncommon  for  a monstrous  formation  of  the  head  to  impede  its  transit : 
the  most  usual  irregularity  in  development  is  a want  of  brain ; and,  as  in 
this  case,  the  head  is  smaller  than  ordinary,  such  a mal-formation  can  in 
no  degree  interfere  with  its  easy  descent.  But  children  are  occasionally 
born  with  tumours  attached  to  the  cranium/)*  These  usually  contain  fluid, 
and,  however  large  they  may  be,  from  their  compressibility  they  would 
offer  but  little  resistance  to  the  accomplishment  of  the  process  of  parturi- 
tion. A collection  of  water  within  the  foetal  skull  itself — constituting 
congenital  hydrocephalus — is  a less  frequent  disease ; though  this  is  also 
very  rare.  It  has  been  my  lot,  however,  to  meet  with  such  an  enlarge- 
ment on  many  occasions.  The  quantity  of  fluid  effused  is  sometimes 
almost  incredible;  three  and  four  pints  have  been  contained,  together  with 
the  brain,  within  the  skull. J Yet  although  the  relative  proportion  between 
the  head  and  pelvis,  necessary  for  the  child’s  easy  passage,  does  not  exist; 
and  the  difficulty  and  danger  must  be  in  proportion  to  the  dimensions  the 

* See  page  86.  To  the  instances  already  mentioned,  may  be  added  that  of  a foetus  pre- 
served in  the  Museum  of  the  Royal  College  of  Surgeons  in  this  city,  which  is  said  to  weigh 
eighteen  pounds.  The  portion  of  navel  string  attached  to  the  umbilicus  proves  that  the  child 
could  not  have  long  survived  its  birth.  It  is  stated,  indeed,  to  have  died  in  its  passage.  » 

t See  Perfect’s  117th  case.  There  is  a preparation  in  the  London  Hospital  Museum,  where 
a tumour  of  hernial  character  is  attached  to  the  vertex  of  an  infant,  more  than  half  the  size  of 
the  head. 

$ In  my  father’s  sixty-eighth  and  sixtyninth  cases,  (Practical  Observations,  Part  I.)  he 
supposed  each  cranium  to  have  held  many  pints  of  fluid.  In  Smellie’s  case  first,  collection 
thirty-one,  (Cases  in  Midwifery,)  three  pints  were  collected  on  the  cranium  being  punctured ; 
and  in  case  twenty,  collection  thirty-five,  between  two  and  three  pints  of  water  were  poured 
into  the  skull  after  the  child’s  extraction,  through  the  opening  by  which  the  hydrocephalic 
fluid  was  evacuated.  In  Perfect’s  last  case,  the  head,  extracted  whole,  the  breech  having  ori- 
ginally presented,  measured  twenty-four  inches  and  one-eighth  in  circumference. 


200 


LINGERING  LABOUR 


head  has  acquired ; it  does  not  follow  as  a matter  of  course  that  the  wo- 
man would  die  undelivered,  if  art  does  not  step  in  to  rescue  her : for  I 
myself  witnessed  a case  immediately  after  its  termination,  in  which  a 
head,  containing  a pint  of  fluid,  was  squeezed  whole  through  the  pelvis,  to 
the  great  danger  of  the  sacro-iliac  ligaments  and  the  pelvic  contents.*  In 
two  other  instances  that  came  within  my  knowledge,  where  putrefaction 
had  occurred  to  a considerable  extent,  the  scalp  burst,  and  the  fluid  was 
evacuated:  the  bones  then  collapsed,  the  difficulty  was  over,  and  the  flat- 
tened head  protruded.  But  in  other  cases, — and  they  are  by  far  the  most 
frequent, — instrumental  aid  will  be  found  necessary  before  delivery  can  be 
effected. 

There  is  great  danger  in  allowing  a dropsical  head  to  remain  for  a long 
time  locked  in  the  pelvic  cavity ; because,  from  its  compressibility  and  the 
open  state  of  the  fontanelles,  it  so  completely  adapts  itself  to  the  shape, 
and  moulds  itself  into  the  irregularities  of  the  cavity,  as  to  occasion  strong, 
uninterrupted,  and  almost  universal  pressure  upon  the  lining  structures,  to 
their  imminent  and  certain  hazard.  We  should  naturally  expect  slough- 
ing to  occur : the  bladder  and  the  rectum  might  be  implicated,  and  a fatal 
termination  result. 

Diagnosis . — Such  being  the  dangers  attendant  on  this  case,  it  becomes 
a matter  of  the  greatest  possible  consequence,  that  we  should  detect  a 
hydrocephalic  head  as  early  in  the  process  as  possible : nor  is  the  diag- 
nosis generally  difficult.  We  may  ascertain  the  existence  of  the  disease  \ 
by  the  volume  of  the  head  being  so  much  greater  than  ordinary,  by  the 
bones  being  so  much  wider  apart,  the  fontanelles  and  sutures  being  more 
open  and  discernible,  and  by  there  being  a certain  degree  of  fluctuation 
evident  within  the  skull.  We  must  not,  however,  rely  implicitly  on  the 
last-named  symptom ; for  the  pressure  which  the  head  is  undergoing  will 
very  frequently  prevent  the  sensation  of  fluctuation  being  communicated  i 
to  the  finger,  even  through  the  distended  anterior  fontanelle.  These  pecu- ' 
liarities  it  will  certainly  not  be  easy  to  discriminate  before  the  os  uteri  is 
dilated  to  a moderate  extent ; or  if  we  are  content  with  inquiring  by  the 
first  finger  of  the  right  hand : but  I have  before  laid  it  down  as  a maxim, 
that  we  should  introduce  two  or  more  fingers  of  the  left  hand,  to  deter- 

* On  arrival  I found  the  woman  just  delivered  of  a dead  hydrocephalic  foetus,  the  circum- 
ference of  whose  head  was  eighteen  inches.  She  suffered  acutely  after  her  labour  from  in- 
flammation of  the  sacro-iliac  ligaments,  consequent  on  the  distending  pressure,  to  which  they 
had  been  subjected  from  within;  and  could  not  walk  without  support  for  ten  or  twelve  weeks. 
This  occurred  in  1823.  In  the  year  1827  I was  called  to  another  patient,  who,  just  before  I 
entered  the  room,  had  expelled  a hydrocephalic  child,  after  a very  severe  labour  of  more  than 
sixty  hours’  duration.  The  head  measured  seventeen  inches  round;  but  I was  not  allowed  to 
ascertain  the  quantity  of  fluid  it  contained.  This  poor  creature  died  within  a week,  from  the 
combined  effects  of  exhaustion  and  inflammatory  action. 


FROM'A  DROPSICAL  HEAD. 


201 


mine  the  cause  of  delay,  provided  the  labour  be  not  progressing  satisfac- 
torily; and  although  the  pelvic  cavity  be  but  little  occupied  by  the  head, 
we  shall  in  most  instances  be  able,  with  care  and  attention,  to  satisfy  our- 
selves of  the  true  nature  of  the  case. 

Treatment. — Having,  then,  detected  a dropsical  head  either  above  the 
brim,  or  partially  occupying  the  cavity  of  the  pelvis,  what  must  be  our 
practice  ? — Are  we  to  act  on  the  principles  I have  before  so  often  enjoined, 
of  waiting  as  long  as  possible,  compatible  with  the  patient’s  strength,  be- 
fore affording  any  means  of  relief? — Are  we  to  incur  the  hazard  of  con- 
tusion, inflammation,  laceration,  and  sloughing  ? — Are  we  to  run  the  risk 
of  the  patient’s  powers  becoming  exhausted  by  useless  struggles ; — of  her 
system  being  so  much  depressed  as  to  endanger  her  sinking  ? — I would 
reply  to  these  queries  by  a decided  negative. — When  we  have  ascertained 
that  nature  is  unable  to  overcome  the  difficulty  except  at  a great  expendi- 
ture of  power,  conjoined  with  imminent  risk  of  the  woman’s  life,  we  are 
fully  warranted  in  having  recourse  to  perforation  more  early  than  if  the 
child  were  healthy,  that  the  fluid  may  be  evacuated,  and  an  opportunity 
afforded  to  the  bones  to  collapse ; the  case  will  then  most  probably  be  ter- 
minated by  the  contractions  of  the  uterus  alone.  I think  myself  justified 
in  offering  this  recommendation,  because  of  the  danger  of  inflammation, 
and  all  the  dreadful  consequences  which  may  follow  impaction  of  the 
head,  and  because  of  the  slight  probability  there  exists  of  the  ultimate  pre- 
servation of  the  child’s  life.  Suppose  even  that  the  infant  was  born  living, 
is  it  likely  to  survive  for  any  length  of  time? — Is  it  probable  that  the  dis- 
ease, originating  in  an  early  period  of  pregnancy,  will  be  removed,  or 
even  suspended  ? — Are  we  not  rather  to  expect  that  it  will  go  on  increasing, 
to  the  ultimate  destruction  of  the  little  sufferer? — Is  the  child,  then,  likely 
to  be  a comfort  to  its  parents  ? — Is  it  likely  ever  to  enjoy  the  perfect  pos- 
session of  its  faculties,  whether  corporeal  or  intellectual  ? — Is  it  likely  to 
become  a useful  citizen,  or  valuable  member  of  society  ? — The  proba- 
bility is  much  against  even  the  least  of  these  advantages. — Can  we,  then, 
for  a moment  put  the  woman’s  safety  in  competition  with  the  preservation 
of  a hydrocephalic  child  ? — If  it  be  objected  that  life  must  necessarily  be 
destroyed  by  adopting  the  measures  just  recommended,  and  that  it  is  the 
duty  of  the  physician  to  preserve  life,  if  possible,  under  the  most  aggra- 
vated circumstances  of  pain,  misery,  helplessness,  and  fatuity,  I would 
acknowledge  the  obligation  on  the  part  of  the  medical  practitioner  to  the 
fullest  extent ; but  I would  also  remark  that  here  is  life  at  issue  against 
lite ; — the  life  of  the  mother  of  a family,  in  other  respects  healthy,  against 
the  puny,  slender,  scarce  animal  vitality  of  an  infant  diseased  beyond  the 
hope  of  surviving,  and  with  little  chance  of  enjoying  even  the  faintest 
gleam  of  intellect.  But  granting  that  the  child  should  pass  alive,  and  the  wo- 
26 


202 


LINGERING  LABOUR 


man  also  be  preserved,  her  structures  must  be  seriously  endangered ; and 
two  miserable  instances  of  sloughing,  when  the  head  was  full  of  serous 
fluid,  have  come  under  my  own  immediate  notice,  occasioned  by  the 
praiseworthy — though  in  the  case  under  consideration,  falsely-founded — 
horror  inspired  by  the  idea  of  craniotomy.  In  following  up  this  practice, 
however,  let  us  beware  of  error : — let  not  our  ignorance  lull  us  into  a fatal 
assurance.  Let  us  be  'perfectly  certain  of  the  existence  of  disease  in  the 
foetal  head  before  we  take  the  perforator  in  hand. — What  an  appalling 
and  sickening  feeling  must  overspread  the  mind  of  that  man  who  plunges 
the  murderous  instrument  into  the  centre  of  the  brain  of  a living,  healthy 
foetus,  under  the  erroneous  belief  in  the  presence  of  hydrocephalus  ! What 
would  his  sensations  be,  when,  instead  of  the  expected  water,  a stream  of  pure 
and  unmixed  blood  flows  from  the  inflicted  wound  ! What  bitter  remorse 
must  overwhelm  him,  when,  after  the  keenness  of  the  first  shock  has  passed 
away,  leisure  is  afforded  him  to  contemplate  the  rashness  and  criminality 
of  his  conduct! — The  mischief  is  done; — the  death-blow  is  struck  ; — the 
act  is  irrevocable  !* 

Fig.  96,  Plate  XXXII.,  shows  a hydrocephalic  head,  which  contained 
about  twenty-four  ounces  of  fluid,  filling  up  the  brim  of  a skeleton  pelvis. 
Fig.  95  is  a front  view  of  the  same  head.  It  is  impossible  to  regard  these 
drawings,  without  being  impressed  with  the  cruelty  we  should  be  guilty  of, 
were  we,  with  a knowledge  of  the  existence  of  the  disease,  to  permit  a 
dropsical  head  to  remain  for  any  length  of  time  either  impacted  in  the 
pelvic  brim,  or  wedged  in  the  cavity. 

3d,  & 4 th.  Unusual firmness,  and  malposition  of  the  head. — As  occasionai- 

* See  an  instructive  case  of  labour,  complicated  with  a hydrocephalous  fetus,  in  the  Medi- 
cal Gazette,  July  3rd,  1840,  communicated  by  Mr.  Robertson,  of  Aberdeen.  In  this  instance 
the  woman  died  forty-five  hours  after  delivery  of  her  eighth  child,  from  the  effects  of  pres- 
sure occasioned  by  the  head,  which  contained  four  pints  pf  wrater,  on  the  organs  situate  at 
the  pelvic  brim.  The  list  patient  T deliyered  of  a hydrocephalic  child  (May  29th,  1840)  had 
been  in  labour  from  Sunday,  when  the  membranes  broke,  to  early  on  Friday  morning,  u'hen  I* 
first  saw  her.  It  was  her  second  child ; her  first  labour  had  been  easy.  The  medical  gentle- 
man in  attendance,  hoping  and  expecting  hour  by  hour  that  the  case  wrould  soon  be  termi- 
nated, did  not  send  for  me  till  pressing  symptoms  of  exhaustion  had  supervened.  She  did  not 
rally  in  any  considerable  degree  from  the  depression  under  which  she  was  delivered,  and  died 
the  same  evening.  This  head  contained  nearly  two  pints  of  water.  Most  of  the  cases  of  this 
description  which  I have  seen  have  been  attended  with  great  agony,  especially  in  the  pubic 
region,  from  the  time  the  liquor  amnii  was  evacuated  till  delivery,  and  some  of  them  even  before 
the  membranes  broke ; and  the  patient,  as  in  Mr.  Robertson’s  case,  has  been  exceedingly  irri- 
table and  restless,  rolling  about  in  every  direction,  and  with  difficulty  preserved  in  one  p -4- 
tion  a sufficient  time  to  make  the  necessary  vaginal  examination.  This  aggravation  of  suf- 
fering arises  from  the  pressure  of  the  distended  cranium  on  the  bladder  and  other  tender 
structures  at  the  pelvic  brim,  which,  in  cases  of  ordinary  labour,  are  not  subjected  to  the 
same  distress. 


Pl.XXXlI 


•Svrusiazr^S  Jitth* 


' 'k'  ■ * S ; 

wmm'--  ' ■ c^' 


• ' ■ -^Ssafefe  » -ma 

: - y •#*'  •-■  ■- 

ttBWRVrt--  ,-Va*  \^vafr 

■ C.'THE  - , •/" 

esivd»ny  of  iuinois 

* 

’ *»  . * .. 

U*  * ■ . V 


. ' ■>. 


FROM  WATER  IN  THE  FCETAL  ABDOMEN.  203 


]y  an  exuberance  of  growth  takes  place  throughout  the  whole  foetal  body,  so 
at  other  times  we  observe  some  of  the  systems  more  particularly  developed 
than  others  ; and  this  is  most  remarkable  in  regard  to  the  skeleton.  The 
cranial  bones  partaking  of  this  increased  deposite  of  osseous  matter  be- 
come thicker,  harder,  and  firmer  than  is  usual ; the  membranous  spaces 
which  separate  them  from  each  other  are  diminished  in  extent ; and  such 
a degree  of  solidity  is  imparted  to  the  entire  head,  that  it  is  incapable  of 
undergoing  that  compression  which  so  materially  lessens  its  lateral  dia- 
meter, and  so  much  facilitates  its  exit.  Proportionate  difficulty  will  there- 
fore be  produced  under  labour,  and  the  same  effects  will  result  as  though 
the  head  was  actually  of  extraordinary  size. 

It  is  not  probable  that  this  peculiar  conformation  will  be  detected  early 
in  the  labour  ; but  when  delay  in  the  descent  of  the  head  appears,  we  may 
be  able  to  satisfy  ourselves,  both  that  it  is  not  larger  than  common,  and 
also  that  it  is  more  strongly  ossified  than  usual,  by  the  introduction  of  two 
or  more  fingers  of  the  left  hand  up  to  the  pelvic  brim,  as  before  more  than 
once  advised.  This  latter  information  we  may  collect  as  well  from  the 
preternatural  solidity  of  its  feel*  as  from  the  indistinctness  of  the  sutures 
and  fontanelles,  and  all  the  small  space  which  they  occupy. 

Regarding  the  treatment  of  such  a case,  I have  nothing  to  offer  beyond 
the  instruction  so  often  inculcated ; — that  we  should  wait  as  long  as  is 
consistent  with  the  woman’s  safety;-  and,  when  compelled,  use  those 
means  most  applicable  to  the  case : the  long  or  short  forceps,  if  the  head 
have  descended  sufficiently  low  to  lie  within  their  grasp ; — the  perforator, 
if  by  its  agency  alone  we  can  snatch  the  patient  from  impending  death. 

Having  already  fully  discussed  the  subject  of  malposition  of  the  head, 
when  treating  of  the  irregularities  of  head  presentation,  no  farther 
notice  of  that  cause  of  lingering  labour  can  be  required  here. 

5th.  Ascites  and  Tympanites  of  the  Foetal  Abdomen. — An  effusion  of 
fluid  will  sometimes  take  place  during  foetal  life'  into  the  thoracic  and 
abdominal  cavities  ;*  both  hydrothorax  and  ascites,  however,  as  congeni- 
tal diseases,  are  very  rare ; the  latter  is  perhaps  the  most  frequent  of  the 
two.  It  is  not  likely  that  any  difficulty  to  the  passage  of  the  child  would 
be  produced  by  a collection  of  water  in  the  chest  alone;  nor  would  an 
abdomen  enlarged  from  the  same  cause,  however  much  increased  in  bulk, 
offer  any  impediment  to  the  birth  of  the  head.  Delay  however  would 
occur,  in  the  transit  of  the  body;  and  if  means  of  relief  were  not  applied, 
the  woman  might  sink  under  her  sufferings,  although  her  child  were 
partly  in  the  world. 

* Sec  my  father's  sixty-seventh  case,  Practical  Observations,  Part  I, 


204 


LINGERING  LABOUR 


The  case  would  be  known  by  the  shoulders  remaining  at  the  outlet  of 
the  pelvis  after  the  birth  of  the  head,  resisting  both  the  expulsive  powers 
exerted  by  the  uterus,  and  the  extractive  efforts  of  the  medical  attendant. 
On  the  hand  being  passed  into  the  pelvis,  along  the  body  of  the  child 
anteriorly,  it  would  detect  the  abdomen,  large  and  distended,  soft  and 
fluctuating,  entirely  blocking  up  the  pelvic  brim,  and  more  or  less  filling 
the  cavity. 

If  our  endeavours  to  perfect  the  birth  by  traction  at  the  neck,  or  by 
hooking  the  finger  or  some  blunt  instrument  under  the  axillae,  were  not 
crowned  with  success,  we  should  be  compelled  to  diminish  the  bulk  of 
the  body,  by  puncturing  the  abdominal  parietes,  and  evacuating  the  con- 
tained fluid.  This  could  easily  be  effected  by  a trochar,  or  even  by  the 
obstetric  perforator.  The  only  objection  which  could  be  started  to  the 
performance  of  this  operation,  consists  in  its  apparent  cruelty ; but  every 
consideration  must  give  way  to  the  preservation  of  the  woman’s  life ; and 
we  shall  mostly  find,  that  the  child  has  ceased  to  exist  before  this  means  of 
delivery  has  become  necessary.  Unless  it  be  breathing  vigorously,  the 
pressure  exerted  on  the  umbilical  cord  will  most  likely  have  destroyed  it ; 
and  that  pressure  must  have  been  carried  to  a great  extent,  if  we  are 
unable  to  withdraw  the  body  without  making  an  opening  into  the  peri- 
toneal sac. 

Tympanites  is  the  effect  of  putrefaction  ; and  gas  may  be  generated  in 
the  abdominal  cavity,  in  the  intestinal  canal  itself,  and  in  the  cellular 
structure  underneath  the  skin. 

We  can  have  no  difficulty  in  determining  that  putrefaction  has  occurred, 
after  the  head  is  born;  the  cuticle  will  desquamate  most  easily,  and  the 
scalp  itself  will  be  emphysematous.  If,  under  this  state  of  things,  diffi- 
culty occur  in  the  passage  of  the  shoulders,  we  can  be  at  little  loss  to 
understand  the  cause ; and  should  we  be  disappointed  in  our  attempts  to 
liberate  the  infant  by  the  finger,  or  blunt  hook  passed  around  the  shoulder, 
we  must  here  also  perforate  the  abdomen,  let  out  the  air,  and  give  an 
opportunity  for  the  body  to  collapse.  The  diminution  in  bulk  will  then 
readily  allow  its  extraction.  When  putrefaction  has  taken  place,  we 
cannot  hesitate  to  operate  in  the  manner  recommended ; for  the  child  being 
certainly  dead,  no  additional  injury  can  be  inflicted  on  its  person. 

6th . Shortness  of  the  Funis  Umhilicalis  has  been  regarded  as  another 
cause  of  lingering  labour  attributable  to  the  ovum.  It  has  been  already 
shown  that  the  umbilical  cord  varies  to  a very  extraordinary  degree,  both 
in  length  and  thickness,  but  particularly  in  length ; so  that  it  sometimes 
measures  five  or  six  feet,  and  in  other  cases  it  has  been  known  scarcely 
to  exceed  six  inches.  Presuming  that  it  is  not  more  than  a few  inches  in 


FROM  A SHORT  UMBILICAL  CORD. 


205 


length,  that  circumstance  alone  has  been  supposed  sufficient  to  prevent 
the  ready  passage  of  the  head.  This  was  particularly  the  opinion  of  the 
ancients,  who  considered  that  the  child  by  its  own  efforts  assisted  greatly 
in  liberating  itself  from  the  uterine  cavity;  and  that  these  efforts  would 
be  frustrated  and  rendered  of  no  avail,  by  its  being  tethered,  as  it  were, 
to  the  uterus,  and  on  that  account  incapable  of  effecting  its  extrication. 

I have,  I trust,  satisfactorily  proved  that  the  child  is  a perfectly  passive 
body  under  labour ; that  no  exertions  of  its  own  facilitate  its  escape ; and 
therefore  this  reasoning  must  fall  to  the  ground.  Under  the  action  of  its 
fibres,  the  fundus  uteri  descends,  and  follows,  as  it  were,  the  child’s  body ; 
there  is,  therefore,  always  nearly  the  same  distance  between  the  umbilicus 
of  the  child  and  the  placenta, — even  though  that  organ  be  attached  high 
up  within  the  womb, — whether  the  uterus  be  perfectly  quiescent,  or 
whether  it  be  acting  vigorously.  So  far,  then,  as  the  head  of  the  child  is 
concerned,  the  shortness  of  the  funis  umbilicalis  can  produce  no  such 
impediment  to  its  exit  as  to  cause  a lingering  labour. 

But  the  case  is  different  when  the  head  has  passed,  and  the  shoulders 
are  about  to  escape ; then,  if  the  funis  umbilicalis  be  preternaturally  short, 
or  rendered  so  by  being  twisted  round  the  body  or  limbs  of  the  foetus,  a 
difficulty  in  the  expulsion  of  the  shoulders  may  be  experienced,  or  danger- 
ous consequences  may  be  produced ; — the  placenta  may  be  prematurely 
separated  from  its  attachment,  or  its  mass  may  be  broken ; a portion  may 
be  expelled,  and  the  remainder,  retained  in  utero,  may  give  rise  to  violent 
haemorrhage. 

Diagnosis. — We  may  suspect  that  a preternatural  shortness  of  the  cord 
impedes  the  passage  of  the  shoulders,  provided  we  find,  after  the  head  is 
born,  that  the  body  of  the  child  does  not  advance,  although  the  uterus 
continues  to  act  strongly ; that  no  preternatural  enlargement  of  bulk  exists ; 
and  if  on  passing  our  finger  up  to  the  umbilicus,  and  endeavouring  to  pull 
down  a loop  of  the  cord,  we  find  it  tense  and  tight,  resisting  all  our  efforts 
to  withdraw  it. 

Treatment — In  a case  of  this  kind  it  would  be  right  not  to  hurry  the 
extraction  of  the  child,  provided  it  be  breathing  freely ; but  to  obtain  all 
the  advantage  derivable  from  the  contraction  of  the  uterus.  By  this 
means  we  shall  best  avoid  the  risk  both  of  immediate  and  eventual 
hsemorrhage : for  as  the  uterus  contracts  more  perfectly,  the  body  will  be 
expelled,  and  the  placenta  will  most  probably  be  separated  at  the  same 
time.  A similar  impediment  may  be  produced,  if  the  funis  be  coiled 
around  the  child’s  neck.  I have  already  adverted  to  the  possibility  of 
this  occurrence,  the  accidents  it  may  occasion,  and  the  mode  of  prevent- 
ing them.* 

* Page  131. 


206  LINGERING  LABOUR  FROM  MONSTROSITY. 

7 th.  Unusual  hulk  of  the  trunk  or  limbs  from  excessive  development. — W e 
sometimes,  though  rarely,  find  that  the  different  foetal  members  do  not 
grow  in  their  just  proportion,  but  that  some  are  deficient,  while  others  are 
abundant  in  development*  Preserved  in  the  London  Hospital  Museum 
there  is  a foetus  measuring  in  length  twenty-four  inches,  whose  shoulders 
are  seven  inches  across,  (the  average  width  being  under  five ;)  while  the 
cranium  is  smaller  than  ordinary.  Such  a prodigious  bulk  would  neces- 
sarily occasion  difficulty  after  the  head  had  passed ; and  the  case  must  be 
met  by  the  common  means.  Taking  especial  care,  if  the  child  be  alive, 
not  to  injure  the  arm  or  the  shoulder-joint,  the  finger,  the  corner  of  a 
handkerchief,  or  a blunt  hook,  must  be  insinuated  first  under  one  axilla, 
then  under  the  other,  traction  may  be  made  by  these  agents ; and  by  per- 
severance our  object  will  generally  be  effected  : for  the  compressibility  of 
the  viscera,  and  the  elasticity  of  the  thoracic  parietes,  are  fortunately  so 
considerable,  as  to  allow  a great  diminution  in  capacity,  and  permit  the 
extraction  of  the  body  through  a comparatively  narrow  channel.  In 
making  such  efforts,  however,  we  must  bear  in  mind  the  delicacy  of  the 
structures  on  which  our  purchase  is  fixed  : we  may  break  the  humerus, 
separate  the  epiphysis,  or  dislocate  the  head  of  the  bone, — accidents  all 
of  serious  consequence, — unless  we  use  the  power  we  are  in  possession  of 
with  the  utmost  tenderness. 

8th.  Monstrosity. — It  may  be  our  fortune  to  meet  with  other  more  rare  and 
more  complicated  species  of  monstrosity.  Plate  LI.  figs.  140  and  141 
delineate  two  specimens  of  double  foetus,*  both  having  arrived  at  the  full 
period  of  intra-uterine  maturity; — the  first,  two  perfect  children  joined 
together  from  the  upper  edge  of  the  sternum  to  the  pubes, — each  possess- 
ing a head  and  proper  complement  of  limbs ; — in  the  second,  the  indivi- 
duals are  attached  to  each  other  by  the  side  of  their  trunks ; and  the  two 
heads  are  appended  to  a body  double  at  the  upper  part,  and  single  below, 
there  being  four  arms  but  only  two  legs.  The  difficulty  and  danger  atten- 
dant on  such  a birth  must  be  great,  and  will  come  under  consideration  at 
a future  opportunity. 

All  these  causes,  then,  may  operate  to  induce  a lingering  labour; 
some  of  them  very  much  impeding  the  expulsion  of  the  head,  and  others 
the  passage  of  body  when  the  head  is  born.  But  the  case  may  be  com- 
plicated with  still  greater  difficulties  than  have  been  described,  by  two  or 
more  of  the  causes  enumerated,  acting  in  concert.  Thus,  an  unfavourable 
position  of  the  head  may  exist,  in  concurrence  with  atony  of  the  uterus. 


In  the  collection  at  the  London  Hospital. 


MANAGEMENT  OF  LINGERING  LABOUR.  207 


or  rigidity  of  parts  ; or  all  three  with  a diminished  capacity  in  the  pelvic 
apertures. — See  Complex  Labours. — Monsters. 

The  management  of  a patient  under  lingering  labour  requires  to  be 
even  more  strictly  regarded,  than  in  a natural  and  common  case;  because 
her  present  comfort  and  future  welfare  depend  much,  as  well  on  our  own 
conduct,  as  on  the  rules  we  lay  down  for  her  guidance. 

The  chamber  should  be  preserved  cool  and  quiet,  to  avert  fever  and 
entice  sleep.  It  is  highly  necessary  that  she  should  not  be  kept  in  one 
posture,  because  of  the  inconvenience,  the  irksomeness,  and  additional  dis- 
tress a constrained  position  must  occasion.  She  may  stand,  walk,  or  lie, 
alternately, — especially  during  the  first  stage, — or  place  herself  in  any 
situation  under  which  she  is  least  uneasy.  We  must,  by  every  persuasive 
argument,  prevent  her  from  bearing  down,  or  using  any  voluntary  efforts, 
for  the  purpose  of  aiding  the  action  of  the  uterus.  The  attendants  in  the 
lying-in  room  often  suppose  that,  when  a certain  number  of  hours  have 
elapsed  since  the  commencement  of  labour,  a proportionate  progress  must 
necessarily  have  taken  place ; and  accordingly,  with  the  best  intentions, 
they  are  constantly  urging  the  patient  to  exert  those  powers  which  are 
under  the  influence  of  her  own  will,  in  the  belief  that  such  exertions  will 
facilitate  the  child’s  birth. 

After  what  has  been  advanced,  it  is  scarcely  necessary  to  revert  to  the 
uselessness  and  danger  of  this  untimely  exercise  of  the  assistant  muscles : 

not  only  may  the  strength  be  prematurely  expended,  which  should  be 

husbanded  for  a future  period ; but  injury  may  arise  from  the  too  forci- 
ble propulsion  of  the  head  against  the  undilated  and  unprepared  pas- 
sages. 

Nor  must  we  think  it  immaterial  to  regulate  the  diet.  I have  already 
said  that  solid  food  should  not  be  allowed  under  labour, — and  this  obser- 
vation holds  good,  particularly  with  regard  to  a protracted  state, — because 
the  nervous  energy  being  principally  directed  into  other  channels,  diges- 
tion goes  on  but  imperfectly.  For  reasons,  also,  before  given,  stimulants 
should  be  avoided : nourishing  fluids  may  be  taken  ad  libitum , and  the 
blandest  are  generally  the  most  desired. 

A great  objection  is  made  to  the  exhibition  of  cold,  and  especially  aci- 
dulated drinks,  under  lingering  labour  ; on  what  grounds  I cannot  under- 
stand ; and  therefore  I would  by  no  means  interdict  them,  if  they  are  grate- 
ful and  palatable.  Effervescent  draughts,  and  the  subacid  fruits,  will  often 
be  found  highly  refreshing. 

With  regard  to  our  own  conduct,  for  the  reasons  before  mentioned,  we 
must  abstain  from  frequent  examinations,  and  from  close  attendance  at  the 
bed-side  of  the  patient.  By  too  great  assiduousness  during  the  first  stage, 


208 


MANAGEMENT  OF  A PATIENT 


we  shall  either  impress  her  mind  with  injurious  anxiety,  or  induce  her  to 
believe  that  the  labour  is  on  the  point  of  being  completed;  and  we  shall 
perhaps  be  adding  disappointment  to  bodily  suffering.  We  must  not  be 
carried  away  by  her  calls  for  “help,”  however  importunate  she  may  be; 
but  reason  calmly  with  her,  and  assure  her  that,  when  the  period  arrives 
at  which  our  assistance  can  be  useful,  our  best  endeavours  shall  be  exerted 
to  mitigate  her  sufferings.  We  must  speak  cheerfully  both  to  her,  and  in 
her  presence ; and  endeavour  to  preserve  not  only  her  confidence,  but  her 
spirits : for  the  feelings  and  passions  exert  a most  powerful  influence  over 
the  progress  even  of  natural  labour. 

The  most  important  duty  of  all,  however,  which  we  have  to  discharge 
under  lingering  labour,  is  carefully  to  watch  the  state  of  the  bladder. 
Every  three  or  four  hours  we  should  place  our  hand  on  the  vesical  region, 
to  ascertain  whether  it  has  become  materially  distended.  It  is  less  diffi- 
cult to  gain  this  information  during  labour  than  when  the  uterus  is  unim- 
pregnated, because,  in  the  latter  case,  the  organ  falls  lower  into  the  pelvic 
cavity,  and  becomes  somewhat  buried  within  the  surrounding  viscera : but 
when  the  abdomen  is  pretty  nearly  filled  by  the  enlarged  uterus,  and  the 
pelvic  cavity  is  more  or  less  occupied  by  the  child’s  head,  the  bladder 
cannot  retire  either  backwards  or  downwards,  but  is  thrown  forwards, 
and  become  so  much  the  more  evident  to  the  hand.  In  making  this 
examination — the  patient  lying  on  her  left  side — we  pass  the  right  hand 
upon  the  abdomen ; and,  presuming  the  membranes  are  ruptured,  we  feel 
rising,  even  above  the  umbilicus,  a hard,  firm,  sulid  tumuur,  which  is  the 
uterus  itself,  on  which  we  can  make  no  impression,  and  which  is  observed 
to  be  sometimes  harder  and  sometimes  softer,  in  proportion  as  alternate 
contraction  and  relaxation  take  place  in  its  fibres.  Beneath  this  we  shall 
find  another  tumour,  more  circumscribed  in  shape,  occupying  the  hypo- 
gastric region,  just  peeping  above  the  pubes,  encroaching  more  or  less  on 
the  cavity  of  the  abdomen  ; varying,  therefore,  in  size,  according  to  the 
quantity  of  urine  it  contains,  and  giving  a certain  degree  of  indistinct  fluc- 
tuation to  the  hands, — sufficiently  perceptible,  however,  for  us  to  determine 
that  the  tumour  is  the  distended  bladder.  But  we  must  not  suppose  that 
in  all  cases  we  shall  feel  the  bladder,  although  it  contain  a considerable 
quantity  of  fluid,  distinctly  evident  in  its  usual  situation;  because  it  may 
have  subsided  to  the  right  or  left  side,  and,  instead  of  being  found  in  the 
centre  of  the  hypogastric  region,  it  may  be  on  one  side  of  the  enlarged 
uterus,  appearing  above  one  or  other  groin ; or  it  may  have  prolapsed  before 
the  head  of  the  child,  Plate  XXXI,  fig.  94,  as  above  described,  offering 
itself  as  a soft  tumour  in  the  pelvic  cavity.  Having  our  mind,  then, 
directed  to  such  possibilities,  we  must  not  at  once  conclude  that  it  is 
empty,  although  it  may  not  be  discoverable  immediately  above  the  pubes. 


FROM  DISTENDED  BLADDER. 


209 


It  is  of  the  utmost  consequence  that  we  should  not  permit  much  urine 
to  collect  under  protracted  labour ; not  only  because  a distended  bladder 
both  adds  greatly  to  the  suffering  endured,  and  interferes  with  the  efficient 
action  of  the  propelling  powers,  but  also  because  of  the  danger  incurred  of 
injury  to  its  own  structure.  It  may  burst, — inflammation  may  attack  its 
lining  membrane,  which  may  terminate  in  the  destruction  of  its  coats ; or 
a fistulous  orifice  may  be  formed  between  its  neck  and  the  vaginal  canal, 
which  disastrous  accident  is  much  more  likely  to  happen  under  an  accu- 
mulation of  water  within  its  cavity,  than  if  it  be  kept  in  a collapsed  state. 

For  information  respecting  the  condition  of  the  bladder,  we  must  de- 
pend only  on  our  own  personal  examination,  and  not  trust  to  the  declara- 
tions either  of  the  patient  or  the  nurse.  We  are  often  told,  in  answer  to 
a general  question,  that  the  water  passes  plentifully  and  freely ; but  if  we 
are  more  minute  in  our  inquiries,  we  find  that  some  fluid  dribbles  away, 
as  the  patient  lies,  with  each  return  of  uterine  contraction  ; and  that  no 
voluntary  evacuation  has  taken  place  for  many  hours.  This  fluid  may  be 
the  liquor  amnii,  or  it  may  be  urine  squeezed  out  of  the  bladder  by  the 
compression  exerted  on  that  viscus  by  the  abdominal  muscles.  In  the 
latter  case,  it  may  be  known  by  its  urinous  odour ; and  the  very  circum- 
stance of  its  being  forced  out  thus  involuntarily  is  a proof  of  the  cavity 
being  over-distended,  or  at  least  of  its  containing  a considerable  quantity; 
for  if  it  were  entirely,  or  nearly  empty,  this  dribbling  would  not  occur. 
So  far  then  from  this  circumstance  satisfying  us,  it  is  the  surest  indication 
of  the  necessity  of  having  recourse  to  artificial  evacuation. 

The  cause  of  this  inability  to  pass  urine  under  labour  will  mostly,  if 
not  always,  be  found  to  consist  in  the  stricture  formed  at  the  neck  of  the 
bladder,  or  in  the  course  of  the  urethra,  by  the  compression  those  organs 
suffer  between  the  foetal  head  and  pelvic  bones. 

Treatment. — When  the  bladder  requires  to  be  artificially  emptied,  the 
catheter  must  be  used ; and  for  this  purpose,  if  the  head  is  occupying  any 
portion  of  the  pelvis,  the  flat  instrument  is  preferable  to  one  of  a round 
form ; because  it  takes  up  less  room  in  the  antero-posterior  direction.  The 
woman  need  not  be  removed  from  the  ordinary  obstetric  position ; and  the 
attendant  passing  the  first  finger  of  his  left  hand  between  the  labia  externa 
will  discover  the  meatus  urinarius  just  within  the  lower  angle  of  the  sym- 
physis pubis,  at  the  extremity  of  the  smooth  groove-like  passage,  named 
the  vestibule.  Guided  by  the  finger,  the  point  of  the  catheter  is  to  be  in- 
sinuated within  the  meatus,  and  wdth  great  gentleness  the  instrument  is 
to  be  slid  upwards,  until  about  three-fourths  of  its  length  is  introduced. 
To  prevent  its  slipping  entirely  into  the  bladder,  it  should  possess  a rest  or 
stop  near  its  outer  end ; such  an  accident  I have  known  twice  happen, 
where  this  precaution  would  have  obviated  the  occurrence. 

27 


210 


LINGERING  LABOUR. 


But  it  is  not  always  that  the  meatus  urinarius  retains  either  its  natural 
position  or  its  ordinary  character  and  feel ; for  the  urethra  being  pressed 
upon  by  the  child’s  head,  its  lower  aperture  is  forced  downwards ; and  is 
thus  thrown  out  of  its  common  situation.  If  this  pressure  is  continued  for 
any  length  of  time,  the  meatus  and  surrounding  parts  become  swollen ; 
and  the  opening  no  longer  affords  those  peculiarities  to  the  touch  which  it 
possesses  in  its  more  natural  condition.  Under  this  state  of  tumefaction 
and  distention,  the  most  unexperienced  person  may  fail  to  recognise  the 
commencement  of  the  urethra  by  the  finger ; and  if  that  be  the  case,  it  is 
far  better  to  submit  the  patient  to  an  examination  by  the  eye,  than  to  run 
the  risk  of  the  serious  and  in  many  instances,  irremediable  dangers,  that 
attend  on  a continuance  of  over-distention.  Should  much  difficulty  be 
experienced  in  guiding  the  tube  into  the  bladder,  we  must  on  no  account 
endeavour  to  force  a passage ; but  some  new  direction  must  be  given  to 
the  instrument ; and  if  our  efforts  are  still  unsuccessful,  an  elastic  catheter 
must  be  substituted.  The  impediment  met  with  to  the  easy  entrance  of 
the  catheter  may  depend  on  the  head  being  tightly  wedged  in  the  pelvic 
cavity,  or  it  may  arise  from  the  urethra  being  twisted  a little  to  one  side, 
out  of  its  natural  straight  course.  In  either  instance,  if  any  attempt  is 
made  to  overcome  the  resistance  by  violence,  the  probability  is  that  the 
point  of  the  instrument  will  pass  through  the  back  part  of  the  urethra  and 
the  coats  of  the  vagina  behind  it  into  the  vaginal  canal,  and  run  up  to  the 
os  uteri ; an  accident  that  has  many  times  come  within  my  knowledge, 
and  which  is  the  more  likely  to  happen,  in  consequence  of  the  structures 
having  been  thinned  by  pressure,  and  perhaps  having  also  suffered  some 
softening,  the  result  of  incipient  inflammation.  When  this  has  unfortu*- 
nately  occurred,  it  may  be  easily  known  by  the  exertion  required  for  the 
introduction  of  the  instrument;  and  by  some  of  the  fluids  which  the  uterus  , 
contained — thick,  greenish,  or  bloody — being  evacuated  through  the  tube 
instead  of  urine.  Mostly  nature  will  repair  the  inflicted  injury  after  labour, 
and  restore  the  urethra  to  a sound  state ; sometimes,  however,  a perma- 
nent fistula  is  the  consequence. 

It  is  scarcely  necessary  I should  insist  on  our  satisfying  ourselves  that 
the  catheter  is  not  plugged,  or  on  the  propriety  of  smearing  it  with  some 
unctuous  substance,  to  facilitate  its  introduction.  A small  basin  must  be 
at  hand  to  receive  the  urine  as  it  flows. 


Order  1l— INSTRUMENTAL  LABOUR. 


Plates  XXXIII.,  XXXIV.,  XXXV.,  XXXVI.,  XXXVII. 


Although  in  skilful,  and  especially  discriminating  hands,  obstetric  in- 
struments must  be  regarded  as  great  blessings  to  the  suffering  sex,  yet  it 
is  a question  with  some  practical  men,  whether  by  their  unnecessary  and 
improper  use  they  have  not  produced  on  the  whole  more  injury  than  good.* 
During  the  long  reign  of  barbarous  surgery,  there  is  ample  evidence  to 
prove  that  instrumental  interference  was  often  most  unjustifiably  had  re- 
course to ; and  there  is  good  reason  to  fear  that  many  women  have 
dragged  on  a miserable  existence  to  the  end  of  their  days,  the  miserable 
victims  of  impatience,  ignorance,  or  violence.  There  is  also  the  same 
cause  for  apprehension  that  in  no  few  instances,  the  child’s,  if  not  the  mo- 
ther’s life,  has  been  sacrificed,  when  patience,  perseverance,  and  reliance 
on  the  natural  powers,  were  the  only  obstetric  auxiliaries  required. 

I would  not  have  it  thought  by  these  observations  that  I am  unable  to 
appreciate  the  advantages  sometimes  resulting  from  instrumental  aid ; or 
that  I would  draw  an  argument  against  a valuable  measure  from  the 
possibility  of  its  abuse.  I know  too  well  that  nature  sometimes  fails  even 
in  her  grandest  and  proudest  work — the  continuance  of  the  human 
species;  and  that  occasionally  both  the  mother  and  her  offspring  would 
be  overwhelmed  in  one  common  fate,  unless  art  stepped  in  to  snatch  them 
from  impending  destruction.  But  I would  endeavour  deeply  to  impress 
upon  the  mind  of  the  young  practitioner  that  urgent  necessity  alone  will 


See  Blundell’s  Principles  by  Castle,  p.  526 , 


212 


INSTRUMENTAL  LABOUR. 


warrant  him  in  taking  an  obstetric  instrument  in  hand;  and  that  when  a 
choice  is  allowed  him,  he  should  leave  nature  to  accomplish  her  own 
purpose, — provided,  indeed,  he  can  with  safety  trust  her. 

In  his  practice  he  will  find  it  much  more  difficult  to  determine  the  time 
when  instrumental  aid  may  have  become  necessary,  than  to  administer 
that  aid ; and  unfortunately,  he  will  find  the  most  deadly  means  most 
easy  of  application.  Many  times,  also,  he  may  be  almost  persuaded 
against  his  own  opinion  to  the  adoption  of  those  means  by  the  urgent  and 
unceasing  solicitations  of  his  patient.  I would  entreat  him  neither  to 
allow  these  considerations  to  weigh  with  his  judgment,  nor  to  let  that  less 
worthy  motive,  a wish  to  take  advantage  of  the  eclat  likely  to  result 
from  a successful  operation,  tempt  him  to  act  contrary  to  his  own  feelings 
of  propriety. 

Two  species. — I have  already  arranged  instrumental  cases  under  the 
second  order  of  difficult  labours,  and  have  divided  that  order  into  two 
species  : 

First , those  which  are  accomplished  by  instruments  perfectly  compati- 
ble both  with  the  life  of  the  child,  and  the  safety  and  continuity  of  the 
mother’s  structures : 

Second,  those  in  which  either  the  child’s  body  must  be  mutilated,  or 
a cutting  operation  be  performed  on  the  mother’s  person. 

Four  kinds  of  instruments,  differing  essentially  in  their  fashion  and 
mode  of  application,  have  been  used  to  overcome  the  lesser  degrees  of 
difficulty  which  we  meet  with ; by  the  employment  of  either  of  these,  the 
labour  is  reduced  to  one  of  the  first  species  of  this  order : they  are  the 
long  and  short  forceps,  the  vectis  and  the  fillet ; — the  latter  means  is  now 
most  properly  discarded  from  British  practice,  in  cases  of  head  presen-  ; 
tation. 

The  instruments  resorted  to  in  the  second  species  of  this  order  of  cases 
are  of  a cutting  character,  and  they  may  be  resolved  into  two  varieties — 
the  first,  those  which  are  applied  to  the  child,  and  are  necessary  for  the 
performance  of  craniotomy,  as  the  perforator  or  craniotomy  scissors,  the 
crotchet,  the  blunt  hook,  and  the  craniotomy  forceps; — the  second,  those 
which  are  applied  to  the  mother’s  person, — by  which  the  Caesarean  sec- 
tion is  performed,  or  the  symphysis  pubis  divided, — the  scalpel,  bistoury, 
and  others,  which  are  auxiliary,  and  sufficiently  well  known  in  surgery 
to  require  no  particular  mention  here. 


SHORT  FORCEPS. 


213 


FORCEPS. 


Among  the  most  ancient  writers  on  medicine  and  surgery  we  meet 
with  no  description  of  any  obstetrical  instrument  at  all  resembling  our 
forceps.  Hippocrates ,*  indeed,  and  Celsus,f  both  allude  to  instruments 
for  the  purpose  of  facilitating  difficult  labour,  but  they  were  of  a kind 
designed  merely  to  extract  the  child  without  reference  to  its  life ; they 
consisted  entirely  of  hooks  and  crotchets ; and  their  use  must  necessarily 
have  mutilated  the  foetal  body. 

The  first  gleam  of  such  a contrivance  sparkles  in  the  works  of  Rhazes, 
the  Arabian,  who  in  the  latter  part  of  the  tenth  century,  described  a fillet 
supposed  to  be  adapted  to  this  purpose.  We  find  in  Avicenna,  whose 
work  appeared  nearly  one  hundred  years  after  Rhazes  wrote,  the  obstetric 
forceps  mentioned  by  name ; but  whether  they  wrere  of  his  own  suggestion, 
or  had  been  in  use  previously,  is  by  no  means  clear : it  is  generally 
believed,  indeed,  that  he  was  the  original  inventor.  J 

It  does  not  come  within  the  limits  of  this  work  to  enter  into  the  history 
of  the  different  powers  suited  to  relieve  the  exigencies  of  parturition,  a 
subject  curious  and  interesting,  but  not  involving  points  of  sufficient  prac- 
tical utility  to  find  a place  here.§  And  I consider  it,  indeed,  of  much  less 
importance  to  discuss  the  merits  of  the  various  alterations  which  the 
forceps  have  undergone,  than  to  obtain  a knowledge  of  the  cases  requiring 
their  assistance,  and  the  mode  in  which  that  assistance  should  be  rendered. 
I am  in  the  habit  of  using  Denman’s  straight  forceps ; and  these  I recom- 
mend to  my  junior  brethren,  at  least  in  the  commencement  of  their  prac- 
tice, in  preference  to  those  with  Levret’s,  or  any  other  lateral  curve, 
because  each  blade  is,  in  shape,  exactly  similar  to  its  fellow ; either  may 
be  introduced  first  or  uppermost ; each  becomes  a right  or  a left  hand 


* Sect.  iii.  de  Superfcetatione.  f Lib.  vii.  cap.  29. 

t After  giving  some  directions,  the  application  of  which  it  is  not  very  easy  to  make  out,  he 
says,  “ Liget  (obstetrix)  feetum  cum  margine  panni,  et  trahat  eum  subtiliter,  valdb  cum 
quibusdam  attractionibus.  Quod  si  illud  non  confert,  administrentur  forcipes , et  extrahatur 
cum  eis  ; si  vero  non  confert  illud,  extrahatur  cum  incisione,  secundtim  quod  facile  sit,  et 
regatur  regimme  foetus  mortui.” — Opera  in  Linguam  Latinam  Redita,  lib.  iii.  cap.  28— Fen. 
21,  tract  2.  In  this  quotation  we  have  a plain  proof  that  both  the  fillet  and  forceps  were  in 
use  among  the  Arabians. 

J I would  take  the  liberty  of  referring  those  of  my  readers  who  are  disposed  to  enter  into 
this  question,  to  some  lectures  which  I delivered  at  the  London  Hospital,  in  the  session 
1833-34,  as  published  in  the  Medical  Gazette  of  that  time,  (vol.  xiv.  p.  226,  ct  seq.;)  and  on 
this  particular  branch  of  the  subject  I can  recommend,  as  an  authority,  Mulder’s  very  erudite 
“ Historia  Forcipum  et  Vectium.” 


214 


INSTRUMENTAL  LABOUR. 


blade,  according  as  it  is  adapted  to  the  pelvis ; and  no  thought  or  calcula- 
tion is  required  as  to  which  should  be  applied  over  the  one  or  the  other 
side  of  the  foetal  skull ; — which  consideration  in  itself  is  very  likely  to 
embarrass  a young  operator,  and  may  be  the  occasion  of  his  failure. 
This  instrument  measures  eleven  inches  and  three-eighths  from  the  extre- 
mity of  the  handle  to  the  tip  of  the  points ; of  which  the  blade  occupies 
seven  inches,  the  handle  the  remainder ; the  groove  for  the  lock  being  three- 
eighths  of  an  inch  deep.  The  greatest  width  between  the  blades  is  about 
their  centre,  and  measures  two  inches  and  seven-eighths;  the  space  between 
the  points  is  exactly  one  inch.  The  fenestra  is  in  the  shape  of  a kite,  but 
considerably  longer  in  proportion  to  its  width : the  blade  in  its  widest 
part,  near  the  extremity,  measures  an  inch  and  three-quarters  across ; the 
extreme  width  of  the  fenestra  being  one  inch  and  three-sixteenths.  The 
blades  spring  from  the  locking  part  in  a regular  sweep  outwards ; there 
being  no  shank,  properly  so  called.  The  whole  instrument  weighs  ten 
ounces  and  three-quarters.  See  Plate  XXXIII.  fig.  97 ; a the  instrument 
closed,  b the  back  view  of  a single  blade. 

Besides  these  peculiarities  necessary  to  be  attended  to  in  choosing  a 
pair  of  forceps,  there  are  many  others  of  less  apparent  moment,  which 
must  not  be  passed  over  without  notice.  They  should  be  manufactured 
of  the  best  tempered  metal,  else  they  are  liable  either  to  break  or  bend. 
The  lock  should  be  formed  rather  loosely,  so  that  when  the  blades  are 
adjusted  one  to  the  other,  there  should  be  a slight  lateral  motion  allowed : 
for  the  space  of  at  least  an  inch  and  a half  from  the  handle,  each  blade 
should  be  of  a uniform  thickness,  that  it  may  be  slid  to  that  extent  within 
the  groove  of  its  antagonist ; for  this,  we  shall  find,  assists  much  in  its 
application  under  labour.  No  shoulders  are  admissible  near  the  lock,  no 
ornamental  ridges,  no  serrated  edges  ; every  portion  of  the  locking  part 
should  be  perfectly  smooth,  and  the  corners  rounded.  The  external  face 
of  each  limb  of  the  blade  should,  of  course,  be  somewhat  convex ; so,  ■ 
indeed,  should  the  internal  also.  All  the  instruments  that  I have  ever  seen 
have  a rounded  convex  external  surface,  that  the  parts  of  the  mother  may  ; 
not  be  injured  ; but  in  many  the  internal  surface  in  contact  with  the  child’s 
face  is  flat.  Every  flat  surface  must  have  two  sharp  edges ; and  if  strong 
pressure  be  applied,  these  edges  will  cut.  To  obviate  the  chance  of 
disfigurement  to  the  child,  then,  the  inside  of  the  instrument  must  be 
slightly  rounded  also. 

Another  point  to  be  attended  to  is,  whether  the  instrument  should  be 
coated.  It  was  the  old  fashion  to  cover  each  blade  entirely  with  leather, 
that  it  might  be  less  formidable  to  the  sight ; that,  in  locking  it,  little  noise 
might  be  made ; and  that  it  might  be  softer  to  the  woman’s  person,  and 
therefore  not  so  likely  to  do  injury.  Many  of  the  instruments  depicted  in 


SHORT  FORCEPS. 


215 


Smellie’s  and  other  plates  are  finished  in  this  way.  This  practice  was, 
in  my  opinion,  objectionable  on  many  grounds.  In  the  first  place  the 
leather  takes  up  room,  and  does  not  afford  strength  equivalent  to  the  space 
it  occupies ; and  we  shall  find  in  difficult  labour,  when  disproportion  from 
any  cause  produces  the  delay,  that  it  is  of  consequence  to  gain  even  the 
minutest  portion  of  an  inch  in  space.  Again,  the  instrument  does  not 
pass  up  so  easily  when  covered  with  leather,  as  when  it  is  plain  and 
polished.  A still  greater  objection,  however,  has  been  urged  against  this 
practice,  and  one  that  has  caused  it  to  be  generally  abandoned.  It  has 
been  supposed  that  infection — the  virus  of  syphilis  or  gonorrhoea,  for  ex- 
ample— has  been  carried  from  a diseased  to  a healthy  person.  If  there 
be  the  slightest  probability  of  such  a sad  accident,  it  would  be  our  bounden 
duty  either  to  discard  the  leather  entirely,  or  to  change  the  covering  after 
each  time  the  instruments  are  used. 

The  only  coating  I would  admit  of  is  a silver  wash  : to  this  there  can 
exist  not  the  slightest  objection ; and  those  who  are  critically  particular  in 
regard  to  the  neatness  of  their  instruments,  may,  without  any  detriment 
to  their  efficacy  or  value,  require  them  to  be  disguised  under  the  specious 
semblance  of  the  precious  metals.  Practitioners  in  the  East  or  West 
Indies,  and  other  warm  climates,  would  do  well  to  incur  this  additional 
expense  in  their  obstetric  forceps,  as  well  as  other  surgical  instruments, 
not  for  the  sake  of  appearance,  but  to  prevent  rust. 

It  must  be  evident  that  when  the  two  blades  are  adapted  to  each  other, 
so  that  a compact  instrument  is  formed,  it  becomes  a lever  of  the  first 
kind — the  resistance  being  at  one  end,  the  moving  power  at  the  other,  and 
the  fulcrum  between  the  two : it  is  to  be  observed  also,  that  this  fulcrum 
is  situated  at  the  joint ; that  it  is  fixed,  and  its  seat  cannot  be  altered ; and 
that,  in  the  action  of  the  instrument,  one  blade  so  completely  antagonises 
the  other,  as  to  leave  but  a slight  probability  of  the  mother’s  structures 
being  seriously  compressed,  provided  it  be  used  with  caution  and  tender- 
ness. There  is  but  one  modern  of  repute  who  has  altered  the  situation 
of  the  fulcrum  ; — I allude  to  Assalini,  so  well  known  by  his  admirable  sur- 
gical forceps  for  the  purpose  of  securing  deep-seated  arteries.  This  in- 
genious surgeon  has  been  by  no  means  so  happy  in  his  attempts  to  improve 
the  obstetric  forceps ; his  fulcrum  is  at  the  extremity  of  the  handles,  so 
that  a lever  of  the  third  species  is  formed, — the  resistance  being  at  one 
end,  the  fulcrum  at  the  other,  and  the  moving  power  in  the  centre.  Every- 
body acquainted  with  the  rudiments  of  mechanics  must  be  aware  that 
much  power  is  lost  by  this  contrivance : this  objection,  however,  would 
be  but  trivial ; for  with  the  common  forceps  we  possess  considerably  more 
power  than  we  can  generally  dare  to  use.  A greater  objection  would  be 
the  chance  of  causing  injurious  pressure  on  the  maternal  structures,  in 


216  INSTRUMENTAL  LABOUR. 

working  the  instrument ; and  this  has  deterred  me  from  making  a trial  of 
them. 

Application  of  the  forceps. — Before  the  short  forceps  can  be  applied, 
the  os  uteri  must  be  entirely  dilated,  and  the  head  must  have  come  down 
into  the  pelvis  sufficiently  low  to  enable  us  to  feel  one  or  both  ears  dis- 
tinctly. The  instrument,  indeed,  can  neither  be  introduced  without  diffi- 
culty, nor  worked  without  danger,  unless  the  mouth  of  the  womb  be  fully 
opened ; and  it  is  necessary  to  touch  one  or  both  ears,  because  they  be- 
come the  guide  to  the  proper  adaptation  of  the  blades.  To  employ  the 
forceps  with  advantage,  then,  the  exact  position  of  the  child’s  head  must 
be  accurately  made  out ; and  this  we  learn  by  paying  attention  to  the 
situation  of  the  ears  as  regards  the  pelvis,  and  to  the  irregularities  in 
their  form.  We  keep  in  mind  that  the  back  part  of  the  organ, — the  helix, 
or  flap, — is  free  and  unattached,  and  looks  towards  the  occiput;  while 
the  tragus  is  bound  more  closely  down,  and  is  directed  towards  the  face. 
Thus  the  position  of  the  ear,  in  respect  to  the  pelvic  cavity,  informs  us 
whether  the  head  has  made  its  turn ; and  the  direction  of  the  different 
points  of  the  organ  itself,  determines  whether  the  face  is  placed  backwards 
or  forwards,  or  sideways. 

As  soon  as  a necessity  for  instrumental  interference  appears,  two  ques- 
tions of  some  importance  will  naturally  offer  themselves  to  our  mind : the 
first,  whether  we  shall  call  in  the  assistance  of  another  practitioner,  to 
advise  us  by  his  counsel,  to  aid  us  in  the  operation,  and  to  divide  with  us 
the  responsibility  of  the  case ; and  the  second,  whether  we  shall  apprise 
the  patient  of  the  necessity  of  such  help,  and  obtain  her  sanction  and  ap- 
proval. So  far  as  the  first  question  is  concerned,  narrow  policy  might 
perhaps  whisper  to  us,  that  we  should  not  unnecessarily  throw  our  cha- 
racters into  the  hands  of  a neighbouring,  probably  a rival,  and  perhaps 
not  very  friendly,  practitioner.  We  may  be  led  to  argue,  that  we  are 
giving  him  an  undue  superiority;  that  he  may  be  tempted  to  take  advan- 
tage of  the  confidence  we  repose  in  him,  to  worm  himself  into  the  good 
graces  of  our  patient ; that  he  may  blazen  it  abroad  he  was  consulted 
in  a case  so  difficult,  that  we  were  incompetent  to  its  management ; and 
that  to  his  judgment  and  dexterity  the  safety  of  the  patient  was  to  be  at- 
tributed. A selfish  and  narrow-minded  feeling  might  prompt  us  to  reason 
thus ; but  I should  hope  there  are  few  men  in  the  profession  who  would 
be  guilty  of  such  a breach  of  professional  etiquette — not  to  say  of  honour 
— as  is  implied  in  this  suspicion. 

But  let  us  even  look  at  the  darkest  point  of  the  picture ; we  will  sup- 
pose it  probable  that  the  person  we  consult  may  take  advantage  of  our 
confidence,  and  endeavour  to  supplant  us  by  specious  misrepresentation : 
still  I would  recommend  that  the  same  principle  should  be  acted  on;  and, 
strong  in  our  own  acquirements,  in  the  integrity  of  our  intentions,  and  the 


217 


short  forceps,  ( Application . ) 

propriety  of  our  conduct,  that  we  should  disregard  the  ill-natured  asper- 
sions which  envy  or  malice  may  circulate  to  our  discredit : for  there  is 
such  a comfort  in  the  division  of  responsibility,  such  a consolation  in 
knowing,  if  the  case  turns  out  ill,  that  we  have  not  acted  entirely  on  our 
own  judgment,  but  that  another  party  has  sanctioned  the  means  employed, 
and  that  all  has  been  done  which  foresight  could  suggest;  that  we  should  be 
unnecessarily  adding  to  the  anxiety  we  must  undoubtedly  feel,  if  we  allowed 
any  petty  jealousy  to  prevent  our  availing  ourselves  of  the  opportunity 
offered; — provided,  indeed,  the  loss  of  time  which  must  elapse  in  seeking 
assistance  would  not  endanger  the  woman’s  safety. 

The  second  question  can  be  more  easily  disposed  of.  I presume  that 
no  operation  in  what  is  called  pure  surgery , is  undertaken  without  the 
concurrence  of  the  patient ; and  I do  not  know  why  we  should  place  the 
obstetric  branch  of  the  science  on  a different  footing,  in  this  respect,  from 
surgery  in  general.  Many  reasons  would  induce  us  to  inform  our  patient 
of  the  necessity  of  relief  being  afforded  her,  and  the  propriety  of  the  means 
we  are  about  to  adopt.  If  instruments  are  had  recourse  to  surreptitiously, 
they  must  be  employed  at  a great  disadvantage ; since  we  cannot,  under 
these  circumstances,  direct  the  position  and  general  management  of  the 
woman  with  sufficient  accuracy : again,  should  it  be  subsequently  disco  - 
vered  that  artificial  delivery  has  been  practised,  it  will  with  great  reason 

be  presumed  that  tho  inetrnmpnta  wprp  ncc»d  /-miv  abtv.  ~ ^ 1 

not  for  her  benefit ; and  should  an  unfavourable  termination  occur,  we 
shall  be  most  justly  censured.  Independently  of  these  reasons,  we  have 
no  object  in  concealing  our  intentions ; for  we  generally  find  the  woman 
quite  ready  to  submit  to  our  opinion,  resigned  to  the  necessity  of  the  ope- 
ration, and  most  willing  to  avail  herself  of  those  means  of  relief  which  we 
have  it  in  our  power  to  apply.  Nay  more  ; we  shall  often  find  greater 
difficulty  in  resisting  the  importunate  entreaties  urged  both  by  herself  and 
her  friends  to  terminate  the  case,  than  to  persuade  them  of  the  necessity, 
when  that  necessity  exists. 

Having,  then,  called  in  the  advice  and  assistance  of  a medical  friend, 
having  concluded  with  him  that  the  patient’s  safety  demands  that  instru- 
mental delivery  should  be  had  recourse  to,  and  that  the  case  is  fitted  for 
the  use  of  the  forceps;  and  having  obtained  the  required  sanction,  we 
must  sit  down  calmly  and  quietly  by  the  bed-side,  and  determine  most 
correctly  the  position  of  the  head,  if  we  have  not  learned  it  before. 

There  are  eight  situations  of  the  head  under  which  the  forceps  are 
available.  The  first  is,  where  it  has  fully  made  its  turn,  with  the  face  into 
the  hollow  of  the  sacrum,  the  occiput  lying  behind  the  symphysis  pubis, 
or  impinging  on  the  upper  margin  of  the  arch,  with  the  right  ear  towards 
the  right  ilium,  and  the  left  ear  to  the  left  side,— offering  itself,  indeed,  at 
28 


218 


INSTRUMENTAL  LABOUR. 


the  outlet  of  the  pelvis,  in  the  position  most  favourable  for  its  exit.  Plate 
XXV.  fig.  82,  and  PI.  XXXIII.  fig,  98.  The  second  is,  where  the  head 
has  passed  the  brim,  and  come  down  into  the  pelvis  diagonally,  with  the 
face  towards  the  right  sacro-iliac  synchondrosis,  the  occiput  to  the  left 
groin,  the  right  ear  under  the  right  groin,  and  the  left  ear  before  the  left 
sacro-iliac  synchondrosis,  Plate  XXIII.  fig.  75,  PI.  XXV.  fig.  81,  and 
PI.  XXXIIJ.  fig.  99.  The  third  is,  where  the  head  offers  itself  just  in  an 
opposite  direction  to  the  last,  with  the  face  looking  backwards  to  the  left 
sacro-iliac  synchondrosis,  the  occiput  forwards  behind  the  right  groin,  the 
right  ear  against  the  right  sacro-iliac  synchondrosis,  and  the  left  ear  behind 
the  left  groin.  Plate  XXIII.  fig,  76.  The  fourth  is  with  the  face  looking 
directly  towards  the  right  ilium,  the  occiput  to  the  left,  the  right  ear  behind 
the  pubes,  the  left  ear  against  the  hollow  of  the  sacrum,  Plate  XXII.  fig.  73. 
The  fifth  with  the  face  to  the  left  ilium,  the  occiput  to  the  right,  the  left  ear 
behind  the  pubes,  and  the  right  looking  towards  the  sacral  cavity.  Plate 
XXII.  fig.  74.  The  sixth  is,  where  the  face  has  offered  itself  anteriorly,  has 
passed  down  diagonally,  looking  to  one  or  other  groin,  and  has  eventually 
been  thrown  behind  the  symphysis  pubis,  the  occiput  having  turned  into  the 
hollow  of  the  sacrum,  the  right  ear  looking  towards  the  left  ilium,  and  the 
left  ear  towards  the  right  ilium ; as  would  be  the  case  in  Plate  XXVIII. 
fig.  87,  while  the  head  was  passing  through  the  pelvic  cavity,  before  the 

shoulders  came  to  occupy  the  sacrum.  The  seventh  case  is  where  the 
ncau  nas  tiisu  uiearuu  me  unm,  wnn  tne  lace  directed  forward, but  where  the 

turn  just  described  has  not  taken  place,  the  face  looking  to  the  right  groin, 
the  occiput  to  the  left  sacro-iliac  synchondrosis,  the  right  ear  to  the  left 
groin,  and  the  left  ear  to  the  right  sacro-iliac  synchondrosis.  Plate 
XXXIV.  fig.  100,  and  PI,  XXIII.  fig.  78.  The  eighth  and  last  case  is 
just  the  reverse  of  this  again — namely,  where  the  face  comes  down  to  the 
left  groin,  the  occiput  to  the  right  sacro-iliac  synchondrosis,  the  right  ear 
towards  the  left  sacro-iliac  synchondrosis,  and  the  left  ear  behind  the  right,: 
groin.  Plate  XXIII.  fig.  77.  In  the  last  two  situations  the  natural  incli- 
nation of  the  head  is  to  turn,  with  the  face  under  the  arch  of  the  pubes. 

When  the  head  is  placed  in  any  one  of  these  situations,  and  the  symp- 
toms require  it,  we  feel  ourselves  warranted  in  attempting  to  deliver  by 
the  short  forceps  — provided  the  os  uteri  be  fully  dilated, — if  we  can  feel 
an  ear  distinctly, — if  there  is  sufficient  space  in  the  bony  passages  for  the 
head  to  emerge, — and  if  the  soft  parts  are  sufficiently  dilated  to  admit  of 
its  exit  without  suffering  serious  injury. 

Before  the  forceps  are  introduced,  the  state  of  the  bladder  and  rectum 
must  be  particularly  attended  to.  Whether  urine  is  detected  by  the  hand 
or  not,  a catheter  should  be  introduced,  that  we  may  assure  ourselves  of 
the  organ  being  perfectly  empty ; and  if  any  difficulty  occurs  in  the  inser? 


SrricZcurs-Zjv&i., 


V . ' . y.'  - \xr*.  - v .i 


LIBRARY  yk*  • 


Of  THE 
UNIVERSITY  Of  ILLINOIS 


♦ 


219 


short  forceps,  (Application.) 

tion  of  the  common  instrument,  a flexible  tube  should  be  employed.  We 
must  also  ascertain  that  the  rectum  be  not  loaded  with  faeces ; and  if  so, 
it  may  be  relieved  by  a simple  enema.  It  is  not  so  necessary  to  insist  on 
clearing  out  the  bowel,  as  on  the  complete  evacuation  of  the  bladder;  and, 
indeed,  when  the  child’s  head  is  fully  occupying  the  pelvic  cavity,  the 
stricture  produced  by  it  is  so  great,  that  it  is  with  extreme  difficulty  a 
clyster  can  be  thrown  up  *,  and  even  when  injected,  the  fluid  only  partially 
returns ; so  that  we  shall  generally  be  foiled  in  our  intention  of  emptying 
the  lower  intestines.  It  is  my  practice  always  to  introduce  the  cathe- 
ter, but  not  to  administer  an  enema,  unless  an  accumulation  of  faeces  in  the 
rectum  be  evident  to  the  finger,  when  introduced  into  the  vagina. 

Mode  of  applying  the  forceps. — I will  describe  the  most  easy  case 
first,  as  illustrative  of  the  mode  in  which  the  forceps  are  to  be  applied, 
assuming  that  the  face  is  in  the  hollow  of  the  sacrum,  the  vertex  present- 
ing, and  the  perineum  somewhat  distended.  Plate  XXXIII.  fig.  98. 

It  is  not  necessary  that  we  should  accoutre  ourselves  in  any  particular 
dress,  or  even  take  off  our  coat,  for  this  operation  ; but  it  is  desirable  that 
we  should  turn  up  our  coat  sleeve,  unbutton  the  wristband  of  our  shirt,  and 
free  the  fore-arm  as  much  as  possible  from  any  ligature  which  dress  might 
produce. 

The  patient  lying  in  the  common  obstetric  position — on  her  left  side — 
must  be  brought  so  close  to  the  edge  of  the  bed,  that  the  nates  may  pro- 
ject somewhat  over,  the  knees  must  be  drawn  up  towards  the  abdomen, 
and  the  feet  planted  against  the  bedpost,  or  supported  by  an  assistant. 
The  object  in  bringing  her  so  near  the  edge  is,  that  the  handle  of  that 
instrument  applied  over  the  uppermost  ear,  may  be  lowered,  and  its 
point  easily  introduced.*  If  we  attempt  to  operate  while  she  remains 
in  the  middle  of  the  bed,  it  will  be  impossible  to  depress  the  handle  suffi- 
ciently ; and  the  point  cannot  be  introduced  unless  the  blade  be  carried  up 
within  the  sacrum,  and  then  turned  forwards  over  the  ear ; by  which  a 
circular  sweep  of  a portion  of  the  pelvis  is  made,  and  the  maternal  struc- 
tures might  be  endangered.  It  is  to  prevent  the  necessity  of  removing  the 
patient  at  all,  that  some  practitioners,  as  Hamilton,  have  adapted  a hinge 
in  the  shank,  and  others,  as  Conquest,  prefer  a handle  attached  to  the  blade 
by  a screw.  The  instrument  having  been  warmed  (by  placing  it  in  hot 
water,  so  as  to  bring  it  as  nearly  as  possible  to  the  temperature  of  the 
body)  and  greased  with  some  unctuous  substance,  two  fingers  of  the  left 
hand,  previously  anointed,  must  be  carried  over  the  uppermost  ear,  which 

* II  is  of  the  greatest  importance  for  the  success  of  our  operation,  that  the  patient’s  posi- 
tion should  be  carefully  superintended.  I have  myself  known  some  instances  of  failure  fur 
want  of  this  very  necessary  precaution. 


220 


INSTRUMENTAL  LABOUR. 


is  generally  the  one  most  easily  distinguishable.  One  blade  of  the  instru- 
ment is  then  to  be  taken  in  the  right  hand  ; being  gently  poised  between 
three  fingers  and  the  thumb,  its  handle  must  be  lowered,  so  that  the  point 
may  slip  up  towards  the  pelvic  brim,  between  the  fingers  and  the  head; 
it  must  be  directed  over  the  ear  by  the  fingers,  which  are  to  act  as  the 
guide,  and  insinuated  upwards  by  a gently  waving  or  wriggling  kind  of 
motion.  In  the  introduction  the  point  must  be  kept  closely  in  contact 
with  the  foetal  head  : the  attempt  must  be  made  in  the  interval  of  pain,  and 
desisted  from  should  uterine  contraction  occur;  and  if  any  material  resist- 
ance oppose  its  passage,  we  must  not  endeavour  to  overcome  the  impedi- 
ment by  force,  but  give  a new  direction  to  the  blade,  a little  more  forward 
or  backward,  in  whichever  way  it  passes  most  easily ; and  thus  gradually 
slide  its  extremity  upwards,  until  its  complete  insertion.  On  its  being  so 
fully  introduced,  that  the  groove  for  the  lock  projects  slightly  beyond  the 
external  parts,  it  must  be  preserved  in  that  situation  by  the  little  finger 
and  thumb  of  the  left  hand,  or  by  an  assistant,  and  we  must  proceed  to 
pass  up  the  second.  This  must  be  introduced,  directed  by  the  fingers,  in 
a similar  manner  to  the  first;  and  if  they  are  both  properly  applied,  the 
groove  of  one  blade  will  fall  into  the  groove  of  the  other,  so  that  they  will 
lock  together  without  difficulty  or  exertion  ; and  nothing  is  left  for  us  to 
do  but  make  extraction.  If  it  should  happen,  however,  as  will  often  be 
the  case,  that  when  the  blades  are  both  introduced,  they  are  not  perfectly 
opposite  to  each  other,  and  consequently  do  not  lock  easily,  they  must  not 
be  wrenched  round,  in  order  to  make  them  fit, — for  by  so  doing  we  shall 
bruise  the  woman’s  parts, — but  we  must  withdraw  the  one  last  introduced, 
and  pass  it  up  in  a different  direction.  We  had  better  withdraw  it  two  or 
three  times  than  lock  the  blades  by  force. 

Another  point  to  be  attended  to  in  the  application  of  the  instrument  is, 
that  we  should  so  introduce  the  blades,  that  the  grooves  to  form  the  lock 
should  be  internal  in  respect  to  each  other,— for  if  this  be  overlooked,  it  is 
impossible  to  fix  them,  unless  each  handle  be  forced  completely  round  the 
other,  or  one  be  withdrawn.  On  closing  the  lock,  we  must  be  particular 
that  none  of  the  soft  parts  be  pinched,  aqd  especially  that  none  of  the 
hairs  are  entangled  within  the  grooves. 

Our  next  indication  is  to  extract ; and  we  must  do  this  with  a regular, 
slow,  waving,  pendulum-like  sweep  from  handle  to  handle,  keeping  the 
instrument  back  to  the  perineum  as  closely  as  we  can,  so  that  traction 
may  be  made  in  the  direction  of  the  axis  of  the  pelvic  brim.  We  extract 
with  the  right  hand,  while  we  support  the  perineum  with  the  left.  If  there 
be  pains,  we  take  advantage  of  them,  and  act  while  they  continue,  resting 
in  the  absence  of  uterine  contraction ; and  the  child’s  head  must  be  relieved 
from  pressure,  during  the  interval  of  action,  by  opening  the  lock.  If  there 


221 


short  forceps,  ( Application . ) 

be  no  pains,  we  imitate  nature,  by  working  for  two  or  three  minutes 
together,  and  then  relax  in  our  exertions  for  the  same  period,  taking  care 
during  the  interval  to  guard  the  lock  by  the  fingers,  so  that  the  blades 
shall  not  slip.  In  the  course  of  a short  time,  we  shall  find  that  the  head 
makes  some  advance, — that  the  perineum  becomes  more  distended,  and 
at  last  the  vertex  will  appear  externally.  The  direction  of  our  power  is 
then  to  be  in  some  degree  changed,  and  we  must  follow  the  axis  of  the 
pelvic  outlet.  We  no  longer  keep  the  handles  close  to  the  perineum,  but 
turn  them  rather  forwards,  and  upwards  towards  the  abdomen;  and,  by 
a continuance  of  the  same  pendulum  kind  of  action,  the  forehead  will 
emerge,  and  eventually  the  face  and  chin ; during  the  passage  of  which, 
the  perineum  will  demand  our  especial  protection. 

In  most  of  Smellie’s  plates  the  handles  of  the  forceps  are  tied  together 
by  a tape ; and  this  practice  is  still  adopted  by  many.  I disapprove  of 
such  a ligature,  because  the  hand  possesses  quite  sufficient  power  to  make 
the  requisite  compression  ; and  because,  if  the  pressure  be  continued  unin- 
terruptedly, the  child’s  life  must  be  placed  in  great  jeopardy ; and  for 
these  reasons  I have  never  myself  employed  it. 

Cautiously  and  tenderly  must  this  iron  instrument  be  used!  We  must 
recollect  that  no  sensation  can  be  imparted  to  the  operator’s  hand  of  any 
injury  that  may  be  done  to  the  woman ; and  we  must  remember  that  one 
injudicious  thrust,  one  forcible  attempt  at  introduction,  one  violent  effort 
in  extraction,  may  bruise,  may  lacerate,  may  destroy ! Bearing  in  mind, 
however,  the  kind  of  case  in  which  it  is  useful  and  admissible ; — bearing 
in  mind  the  principle  on  which  it  ought  to  be  employed ; — recollecting 
that  it  is  a lever  of  the  first  kind  ; — that  the  metallic  blades  have  no  feel- 
ing, and  cannot  communicate  to  our  perceptions  a knowledge  of  any 
mischief  we  may  inflict,  we  are  not  likely  to  fall  into  any  grave  error  in 
its  application  or  its  use. 

Mode  of  applying  the  forceps,  when  the  head  has  entered  the  pelvis , 
before  making  its  turn. — But  we  may  be  driven  to  the  use  of  the  forceps 
before  the  head  has  made  its  turn  with  the  face  into  the  hollow  of  the  sa- 
crum, while  it  is  lying  diagonally  with  the  face  to  the  right,  Plate  XXXIII., 
fig.  99,  Plate  XXIII.  fig.  75,  or  left,  fig.  76,  sacro-iliac  synchondrosis,  or 
laterally  to  the  right,  Plate  XXII.  fig.  73,  or  left  ilium,  fig.  74.  It  is  very 
evident  that  in  this  case,  although  the  head  may  be  sufficiently  low  to 
enable  the  finger  easily  to  command  the  ear,  still  it  cannot  be  expelled  or 
extracted,  until  it  is  placed  in  a more  favourable  situation  for  its  exit.  It 
has  been  already  more  than  once  demonstrated  that  the  short  diameter 
of  the  outlet  of  the  pelvis  is  from  side  to  side,  and  the  long  diameter  from 
the  fore  to  the  back  part,  which  is  just  the  reverse  of  the  brim ; and, — 
inasmuch  as  the  long  diameter  of  the  head,  while  lying  in  this  position,  is 


222 


INSTRUMENTAL  LABOUR. 


in  the  direction  of  the  short  diameter  of  the  outlet,  and  nature  will  not 
effect  the  necessary  turn, — we  must  perform  it  for  her,  before  extraction 
can  be  accomplished.  This  is  then  a more  complicated  case  than  the 
one  just  described — the  symptoms  are  the  same — the  reason  why  we 
should  employ  instruments  are  the  same — but  the  mode  of  using  them 
somewhat  varies.  It  is  probable  that  in  this  case  we  shall  not  be  able  to 
feel  the  ear  which  is  placed  posteriorly ; but  that  towards  the  pubes  may 
be  detected  readily ; and  this  is  all  that  is  necessary  for  the  purpose : 
because,  if  we  distinguish  one  ear,  that  will  become  an  index  to  the  other  ; 
and  if  we  pass  a blade  over  it,  and  make  the  second  blade  a perfect 
antagonist  to  the  one  first  introduced,  both  must  be  properly  adjusted. 
Having  introduced  the  forceps  with  the  cautions  and  gentleness  before 
inculcated,  the  same  pendulum-like  sweep  must  be  used  for  extraction  ; 
but  independently  of  our  extractive  effort  downwards,  we  must  make  a 
slow  rotatory  motion,  the  wrist  being  directed  outwards  or  inwards, — in 
regard  as  the  face  lies  to  the  right  or  left  side, — so  as  to  throw  it  into 
the  hollow  of  the  sacrum ; by  which  means  we  convert  the  case  into 
one  of  the  first  kind.  We  can  generally  make  this  turn  without  any 
great  difficulty ; but  before  we  attempt  it,  it  is  indispensable  that  we 
should  have  accurately  learned  to  which  side  the  face  was  originally 
looking. 

When  the  face  is  towards  the  right  side,  our  object  being  to  turn  it  into 
the  hollow  of  the  sacrum,  the  motion  of  the  wrist  must  be  inwards,  or  that 
of  semi-pronation ; but  when  it  is  towards  the  .left  side,  it  must  then  be 
directed  outwards,  in  the  mode  of  semi-supination.  But  it  will  naturally 
be  asked  how  we  are  to  know  when  the  face  is  in  the  hollow  of  the  sacrum. 
This  knowledge  may  be  very  easily  acquired.  If  the  blades  have  been 
applied  over  the  ears,  as  they  should  be,  the  rivets  in  the  handles  will  be 
brought  into  a line  with  the  tuberosities  of  the  mother’s  ischia,  as  soon  as 
the  head  has  completed  this  turn,  but  not  till  then.  This  being  accom- 
plished, extraction  may  be  commenced.  It  is  in  the  application  of  the 
instrument  under  this  diagonal  position  of  the  head  that  the  straight  for- 
ceps are  preferable  to  those  with  a lateral  curve,  in  the  hands  of  a young 
operator.  The  curved  instrument  of  Levret  and  Osborn  possesses  a right 
and  a left  hand  blade,  and  requires  to  be  adapted  to  the  head  so  that  the 
convex  edge  should  look  towards  the  face,  and  be  directed  along  the  con- 
cavity of  the  sacrum,  after  that  the  head  has  made  its  turn  and  is  passing 
outwards ; and  it  requires  no  little  consideration,  so  to  adjust  the  blades 
that  the  convexity  may  fit  into  the  curve  of  that  bone.  Should  the  con- 
cave edge,  by  mistake,  be  directed  backwards,  the  points  projecting  beyond 
the  child’s  head  will  rub  against  the  posterior  part  of  the  pelvis,  and  most 
probably  produce  injury.  It  is  by  no  means  impossible  that  this  accident 


223 


short  forceps,  {Application.) 

may  occur  to  one  unpractised  in  operative  midwifery;  and  while  such  a 
possibility  exists,  it  is  much  better  to  have  recourse  to  those  means  which 
are  least  likely  to  do  harm.  The  advocates  for  the  use  of  the  curved 
instrument  allege  that  it  embraces  the  head  by  more  points  of  contact 
than  the  straight.  This  may  be  true ; but  even  granting  their  position, 
that  superiority  would  not  counterbalance  the  chance  of  disasters  likely  to 
arise  from  a mal-application  of  the  blades. 

Occiput  in  the  hollow  of  the  sacrum. — In  the  sixth  case, — where  the 
face  has  come  forward,  and  the  head  has  made  a turn,  with  the  occiput 
into  the  hollow  of  the  sacrum,  and  the  face  behind  the  pubes,  it  has  not 
taken  a fortunate  position  for  its  eventual  exit ; and  although  the  woman 
may  have  had  children  before,  still  it  is  very  probable  that  this  will  not 
pass  by  the  unaided  efforts  of  nature.  Our  indication  here  is  evidently  to 
extract  the  child  as  it  lies,  although  the  situation  is  not  the  most  favoura- 
ble that  could  be  chosen.  I should  presume  no  one  would  think  of  turn- 
ing the  face  in  the  hollow  of  the  sacrum  before  extracting,  because  nature 
has  already  accomplished  the  greater  part  of  the  difficulty — that  of  bring- 
ing the  long  diameter  of  the  head  into  a line  with  the  long  diameter  of  the 
pelvic  outlet.  The  same  care  is  requisite  in  the  introduction  of  the  for- 
ceps in  this  case  as  in  others ; but,  in  extracting,  the  handles  must  be  kept 
farther  back  towards  the  perineum,  because  the  face  will  require  a greater 
sweep  to  clear  the  pubes,  than  the  occiput  would  if  it  were  forward  : the 
head  does  not  adapt  itself  so  commodiously  to  the  passages ; the  bones  do 
not  overlap  each  other  so  completely ; its  general  figure  does  not  become 
so  conoid,  and  consequently  considerably  more  room  is  required  for  its 
transit. 

Face  towards  either  groin. This  situation  of  the  head,— as  the  others, — 
may  be  learned  by  the  position  of  the  ear  and  attention  to  its  figure.  If 
the  face  is  looking  to  the  right  groin,  Plate  XXIV.  fig.  78,  the  right  ear 
will  be  felt  behind  the  left  groin,  with  the  helix  directed  downwards,  as 
the  woman  lies  on  her  left  side : if  to  the  left,  Plate  XXIII.  fig.  77,  the  left 
ear  will  be  discovered  behind  the  right  groin,  with  the  helix  directed  up- 
wards. But  in  making  our  examinations  for  this  purpose,  we  must  be 
careful  not  to  double  the  flap  upon  itself,  otherwise  we  may  be  lamentably 
deceived  in  regard  to  the  direction  of  the  face.  The  instrument  must  be 
introduced  over  the  ears,  in  the  same  manner  as  before.  In  this  case  we 
have  the  choice  of  two  methods  by  which  to  extract  the  head— we  may 
either  bring  the  face  under  the  pubes,  making  a quarter  turn  along  the 
half  pelvis,  or  we  may  make  a three-quarter  turn,  and  throw  it  into  the 
hollow  of  the  sacrum.  Of  these  modes  I should  certainly  prefer  that  in 
which  there  is  the  least  turn  to  be  made— namely,  with  the  face  under 
the  pubes,  provided  it  could  be  effected  ; because,  we  are  less  likely  to 


224 


INSTRUMENTAL  LABOUR. 


do  injury  to  the  mother,  and  also  to  the  child.  If  we  make  a three-quar- 
ter turn,  we  may  injure  the  mother’s  parts  by  bruising,  and  perhaps  by 
laceration  ; and  we  might  even  destroy  the  child : for  if  its  body  be  strongly 
embraced  by  the  contracted  uterus,  and  do  not  follow  the  extensive  turn 
which  we  cause  the  head  to  make,  we  must  infallibly  twist  its  neck  consi- 
derably; and  we  might  dislocate  the  vertebrae,  to  the  destruction  of  its 
life.  But  although  I recommend  that  an  endeavour  should  be  made  to 
bring  the  child  with  its  face  forward,  still  if  it  will  not  pass  in  that  direc- 
tion, without  great  exertion  being  used,  rather  than  have  recourse  to  the 
horrible  expedient  of  craniotomy,  I would  advise  that  the  method  of  act- 
ing should  be  changed,  and  the  face  turned  into  the  hollow  of  the  sacrum. 
I have  frequently  effected  this  alteration  in  position,  though  it  is  usually 
attended  with  some  difficulty.  Plate  XXXIV.  fig.  100,  shows  the  forceps 
applied,  the  face  being  directed  to  the  right  groin.  The  bladder  is  here 
represented  considerably  distended ; under  such  a state  the  action  of  the 
instrument  must  endanger  its  structures. 

Here,  again,  we  remark  the  superiority  of  the  straight  over  the  laterally 
curved  forceps ; for  it  is  evident,  if  we  apply  a curved  instrument  while 
the  head  is  in  this  diagonal  situation,  with  the  intention  of  causing  the 
occiput  to  sweep  the  perineum,  the  convex  edge  must  be  towards  the  occi- 
put, and  the  concave  towards  the  face.  If,  then,  we  should  fail  in  bring- 
ing the  face  under  the  pubes,  and  endeavour  to  direct  it  backwards,  the 
blades  must  be  withdrawn  and  re-adjusted,  each  over  the  opposite  side  of 
the  head  to  that  on  which  it  was  first  adapted,  to  prevent  the  points  of 
the  instrument  rubbing  against  the  structures  at  the  posterior  part  of  the 
pelvis  ; since  they  would  project  considerably  beyond  the  chin.  Thus,  by 
the  withdrawal  and  re-adaptation  of  the  instrument,  the  operation  would 
be  greatly  complicated.  As  the  straight  blades,  on  the  contrary,  are  per- 
fectly similar  in  form,  the  rotation  may  be  accomplished  without  in  the 

least  disturbing  their  position. 

• 

Symptoms  indicating  the  propriety  of  employing  the  forceps. — Some 
practitioners  of  repute  deduce  their  rule  for  the  propriety  of  having  re- 
course to  the  forceps,  principally  from  time;  they  say,  that  when  the  patient 
has  been  twelve  or  twenty-four  hours  in  strong  labour  from  the  period  at 
which  the  membranes  broke,  we  are  warranted  in  having  recourse  to  the 
short  forceps,  provided  we  can  employ  them  without  injury.*  Though 
by  no  means  of  universal  application,  this  rule  is  not  to  be  despised : 
nevertheless,  it  must  be  received  with  much  limitation  ; because  some  wo- 
men will  bear  up  against  the  fatigue  of  labour  for  twenty-four  hours  with 

p 

* Blundell’s  Obstctricy,  by  Castle,  p.  530 


INDICATIONS  FOE  USE  OF  FORCEPS. 


225 


less  exhaustion  of  the  constitutional  powers  than  others  will  sustain  in 
six.*  And  the  converse  of  this  position  holds  equally  good  ; for  in  some 
cases  we  should  not  be  justified  in  having  recourse  to  instruments,  although 
the  twenty-four  hours  had  passed;  because  the  system  will  have  suffered 
comparatively  in  a trifling  degree. 

Others  tell  us  that  we  are  to  pay  little  attention  to  time,  but  look  chiefly 
to  the  symptoms  present.  This,  to  a certain  extent,  is  also  true ; but  the 
parts  will  not  sustain  pressure  for  a continued  length  of  time  without  suf- 
fering injury*  I have  already  mentioned,  that  if  the  head  have  been  im- 
pacted for  four  hours  without  advance  and  recession,  I think  we  are  war- 
ranted in  delivering,  merely  for  the  purpose  of  preserving  the  soft  struc- 
tures uninjured. 

Drs.  Hunter,  Denman,  and  Osborn,  trusted  cases  of  labour  almost  en- 
tirely to  nature.  Osborn, f in  stating  the  symptoms  requiring  the  use  of 
forceps,  says,  “ All  the  powers  of  life  are  exhausted,  all  capacity  for  far- 
ther exertion  is  at  an  end ; and  the  mind  as  much  depressed  as  the  body, 
they  would  at  length  both  sink  together  under  the  influence  of  such  con- 
tinued but  unavailing  struggles,  unless  rescued  from  it  by  means  of  art.” 
Here  we  recognise  a complete  wreck  of  the  powers  of  life ; and  as  BurnsJ 
justly  remarks  on  this  passage,  if  such  a state  be  allowed  to  take  place, 
the  exertions  of  art  will  in  general  prove  as  unavailing  as  the  struggles  of 
nature ; if  all  capacity  for  farther  exertion  is  at  an  end,  we  can  scarcely 
expect  the  system  to  rally.  Denman§  also  says,  “ As  long  as  the  efforts 
of  the  mother  continue  with  any  degree  of  vigour,  there  is  always  reason 
to  hope  that  they  will  ultimately  accomplish  the  effect  of  expelling  the 
child  without  any  artificial  assistance ; in  which  case  the  use  of  the  for- 
ceps is  not  required.”  Again,  he  says,  “ A practical  rule  has  been  formed 
that  the  head  of  the  child  shall  have  rested  for  six  hours  as  low  as  the  peri- 
neum, that  is,  in  a situation  which  would  allow  of  their  application,  before 
the  forceps  are  applied,  although  the  pains  should  have  altogether  ceased 
during  that  time;”  so  that  if  the  head  have  been  on  the  perineum  two  hours, 
and  the  woman  be  sinking  from  exhaustion,  according  to  this  rule,  he  would 

* Early  in  the  year  1834,  I was  called  to  a patient  in  a state  of  depression,  from  which  she 
never  recovered,  although  not  more  than  six  hours  had  elapsed  since  the  rupture  of  the  mem- 
branes.  I delivered  her  under  the  worst  symptoms  of  exhaustion,  such  as  cold  extremities  and 
dark  vomiting.  She  had  been  in  health  previously  to  the  accession  of  labour  : there  had  been 
no  haemorrhage  nor  laceration,  nor  any  cause  for  her  depression,  except  the  fatigue  consequent 
on  great  exertion.  In  this  case  death  would  probably  have  taken  place  long  before  the  twenty- 
four  hours  had  expired. 

t Essays  on  the  Practice  of  Midwifery,  p.  GO. 

t Principles  of  Midwifery,  fifth  edition,  p.  422. 

§ Chapter  xi.  sect.  4 

29 


226 


INSTRUMENTAL  LAHOUK. 


allow  four  more  hours  to  elapse  before  he  would  think  of  having  recourse 
to  the  forceps. 

We  must  take  these  recommendations  of  Hunter,  Osborn,  and  Denman, 
however,  with  some  limitation,  and  recollect  that  they  lived  at  an  age 
when  instrumental  interference  was  frequently  had  recourse  to  unnecessa- 
rily; that  nature  was  seldom  or  never  allowed  to  accomplish  her  object; 
but  the  hand  was  constantly  thrust  into  the  vagina  and  uterus,  to  dilate 
the  parts ; — instruments  were  employed  to  extract  the  child ; — and  the 
rudest  means  were  used  to  bring  away  the  placenta.  A most  beneficial 
object,  then,  was  gained  by  the  recommendations  of  these  great  men,  and 
the  strong  language  in  which  they  clothed  their  instructions : a great  revo- 
lution was  gradually  effected  in  the  practice  of  the  age,  and  obstetricians 
were  taught  to  rely  more  implicitly  on  the  powers  and  beneficence  of  na- 
ture. But  however  useful  it  might  have  been  during  the  lapse  of  the  last 
century  to  paint  in  glowing  colours  the  dangers  of  instrumental  inter- 
ference, and  the  all-sufficient  agency  of  nature,  the  cautions  then  incul- 
cated are  fortunately,  in  a great  measure,  uncalled  for  at  the  present 
time. 

If  we  were  to  follow  implicitly  the  doctrines  of  those  who  regard  nature 
as  capable  of  surmounting  all  difficulties,  we  should  be  led  to  the  conclu- 
sion, that,  provided  the  child  were  born  without  artificial  aid,  the  mother’s 
structures  could  not  possibly  be  endangered ; while,  on  the  contrary,  they 
must  necessarily  receive  injury  under  the  use  of  the  forceps,  however 
skilfully  employed.  But  these  positions  are  both  far  from  true ; for  on  the 
one  hand,  in  many  instances  where  the  labour  has  been  wholly  unassisted, 
and  the  termination  been  perfectly  natural  the  pressure  caused  by  the 
child’s  head  on  the  parts  within  the  pelvis  has  produced  sloughing  and 
subsequent  death ; while,  on  the  other,  the  instrument,  if  properly  and  ten- 
derly applied,  and  used  in  a legitimate  case  does  not  occasion  more  pres- 
sure or  pain  than  would  have  been  suffered  if  the  case  had  been  concluded 
by  nature.  During  extraction,  indeed,  there  may  be  some  aggravation 
of  suffering ; but  that  pain  is  comparatively  speedily  terminated ; and  in 
the  generality  of  instances  the  aggregate  quantity  is  less  than  the  patient 
would  have  undergone,  had  she  been  trusted  to  her  own  powers,  even  if 
they  had  expelled  the  fcetus  unaided.  It  may  be  supposed  that  the  steel 
must  produce  more  pressure  than  the  child’s  head  ; and  this  may  be  in 
some  measure  correct;  but  it  must  be  recollected  also  that,  independently 
of  the  instrumental  pressure  being  continued  for  a short  time  only,  the 
closing  of  the  blades  occasions  a diminution  in  the  lateral  diameter  of  the 
head,  which  must  in  the  same  degree  relieve  the  maternal  structures ; the 
space  thus  gained  being  more  than  the  thickness  of  the  double  blades. 

To  determine  the  precise  period  at  which  the  forceps  are  required,  or 


INDICATIONS  FOR  USE  OF  FORCEPS.  227 


may  be  used  with  safety  and  advantage,  is  one  of  the  nicest  points  that 
can  be  forced  upon  the  attention  of  the  practitioner.  The  principal  evils 
that  we  have  to  fear,  are  the  sinking  of  the  patient’s  strength  through  ex- 
haustion, laceration  of  the  uterus  or  vagina;  such  a contusion  of  the  vagina 
and  perineum  as  to  produce  subsequent  inflammation,  suppuration,  or 
sloughing,  and  inflammation  of  the  uterus,  from  excessive  action. 

With  these  evils  before  us,  we  should  steer  a middle  course  between  the 
two  orders  of  practitioners  just  mentioned,  and  deduce  our  indications 
partly  from  time,  but  principally  from  symptoms;  taking  care  at  the  same 
time  that  the  patient’s  strength  is  not  so  far  exhausted,  before  aid  is  given, 
as  to  render  recovery  hopeless ; for  surely  that  man  who  allows  death  to 
steal  on  by  slow  degrees,  through  his  own  ignorance,  timidity,  or  supine- 
ness, is  at  least  equally  culpable  with  him  who  employs  harmless  means 
rather  earlier  than  absolutely  necessary,  with  the  honest  intention  of  re- 
lieving his  patient  from  present  suffering,  removing  her  out  of  the  chance 
of  extensive  injuries,  or  snatching  her  from  threatened  dissolution.  It 
must  not  be  supposed,  however,  that  I am  an  advocate  for  the  frequent 
employment  of  instrumental  means,  although  of  a character  to  do  no  in- 
jury. I merely  wish  to  state  my  conviction  that  such  assistance  had 
better  be  rendered,  rather  before  it  is  actually  called  for,  than  be  delayed 
till  it  be  rather  too  late . 

The  rule  which  I offer  for  the  guidance  of  the  younger  members  of  the 
profession,  is  taken  from  a number  of  circumstances  in  combination. 
First,  we  must  attend  to  the  previous  history  of  the  woman.  If  she  have 
hitherto  been  in  good  health,  and  is  well  formed,  she  is  so  much  more 
likely  to  bring  her  child  into  the  world  without  assistance ; if,  however, 
she  have  been  confined  for  any  length  of  time  by  illness,  we  should  expect 
the  powers  of  th'e  system  might  not  be  sufficient  for  the  end  proposed. 
But  this  observation  by  no  means  applies  universally,  for  in  the  last  stages 
of  the  most  debilitating  diseases — such  as  dropsy  and  phthisis — the  labour 
is  usually  terminated  naturally.  Again,  if  the  patient  has  had  children 
before,  we  should  expect  that  this  may  be  born  also ; unless,  indeed,  the  head 
be  very  large,  or  strongly  ossified,  or  wrongly  placed,  or  hydrocephalic. 

Secondly , we  must  look  to  the  duration  of  the  labour.  This  is  generally 
attended  to  by  the  patient  and  her  friends,  (who  are,  of  course,  unable  to 
form  a judgment  by  symptoms,)  more  than  any  other  circumstance.  It  is 
certainly  a good  general  rule  to  consider,  that  if  the  labour  has  lasted 
more  than  twenty-four  hours  from  the  rupture  of  the  membranes,  there  is 
a great  probability  that  instruments  will  be  required ; and  that  if  the  head 
has  been  impacted  four  hours,  the  soft  parts  must  be  much  endangered. 

Thirdly , we  must  regard  the  progress  of  the  labour.  If  the  head 
advances  at  all,  and  be  not  impacted,  provided  the  strength  and  spirits 


228 


INSTRUMENTAL  LABOUR. 


are  good,  there  is  seldom  need  to  interfere;  but  if  no  progress  have  been 
made  for  a number  of  hours,  and  especially  if  impaction*  should  have 
existed  for  four  hours,  then, — provided  an  ear  can  be  felt, — and  the  parts 
are  not  so  rigid  as  to  endanger  laceration,  we  are  justified  in  employing 
the  forceps. 

Fourthly , we  must  consider  the  remaining  strength.  Women  often 
suppose  they  are  sinking,  and  will  be  earnest  in  their  declarations  that 
they  have  not  strength  left  to  go  through  their  labour,  when  their  power 
is  unimpaired ; although  there  may  be  a feeling  of  weariness.  There  is 
no  word  so  much  abused  in  the  lying-in  room  as  exhaustion.  The  patient 
will  often  assure  us  she  is  perfectly  exhausted,  when  the  uterus  is  acting 
with  undiminished  energy ; the  solicitous  friends  will  echo  the  same 
sentiment,  while  she  is  walking  about  the  room,  leaning  on  her  nurse’s 
arm. 

Exhaustion  is  accompanied  and  known  by  a very  quick  pulse ; if  it  be 
under  one  hundred  beats  in  a minute,  there  is  seldom  occasion  for  appre- 
hension ; but  if  it  have  gradually  mounted  to  one  hundred  and  twenty,  one 
hundred  and  thirty,  or  one  hundred  and  forty,  our  suspicions  should  be 
awakened  to  the  probability  of  approaching  exhaustion.  It  is  also  known 
by  the  pains  gradually  subsiding  in  frequency,  strength,  and  duration. 
We  must  not  confound  with  this  state  the  sudden  suspension  of  uterine 
action,  which  we  sometimes  observe  in  the  progress  of  the  most  natural 
labour,  and  which  we  can  seldom  account  for ; the  pulse,  tongue,  counte- 
nance, and  spirits,  remaining  good  and  unaltered  ; — when  the  pains  decline 
from  a countinuance  of  exertion,  there  are  other  accompanying  symptoms 
which  powerfully  indicate  distress. 

Another  proof  of  commencing  exhaustion  is  a peculiar  olive-coloured 
discharge  from  the  vagina  ; and  this  symptom  usually  is  not  sufficiently 
attended  to.  I seldom  or  never  saw  a case  in  which  exhaustion  was 
approaching,  that  was  not  accompanied  by  this  characteristic  uterine 
discharge.  Sometimes  there  is  merely  a stain  on  the  linen,  at  others  it 
flows  away  in  large  quantity.  It  possesses  a faint  and  unpleasant  odour, 
though  not  in  the  least  putrid,  This  discharge  has  been  looked  upon  as 
meconium  mixed  with  the  liquor  amnii ; and  its  appearance  has  been 
considered  as  a sure  test  of  the  death  of  the  child,  because  it  is  generally 

# By  the  terms  impacted,  jammed , or  locked  head,  is  understood  that  state,  in  which  it 
neither  advances  during  the  presence,  nor  retreats  in  the  absence  of  uterine  contraction ; when 
it  remains  fixed,  occasioning  strong,  constant,  and  universal  pressure  on  the  soft  parts  within 
the  pelvic  cavity.  It  differs  from  the  more  simple  arrested  condition,  which  merely  means 
such  an  absence  of  actual  progression  with  each  return  of  pain,  as  to  render  the  labour  for 
the  tune  stationary  ; but  in  which  the  parts  are  relieved  from  continued  pressure  by  the  head 
receding  in  the  interval  of  the  parturient  throes. 


INDICATIONS  FOR  USE  OF  FORCEPS.  229 

supposed,  that  when  the  head  is  presenting,  the  meconium  would  not  appear 
externally,  unless  it  had  been  voided  from  the  bowels  in  the  last  death- 
struggle.  I am  persuaded,  however,  that  it  is  not  meconium ; and  1 have 
known  many  children  born  alive,  who  had  been  declared  dead  from  this 
erroneous  impression.  I believe  it  consists  in  an  altered  secretion  from 
the  lining  membrane  of  the  uterus,  consequent  upon  great  exertion  and 
long-continued  action  and  look  upon  it  as  one  of  the  first  indications  of 
exhaustion. 

Again:  exhaustion  is  known  by  the  breathing  being  hurried,  by  the 
countenance  becoming  anxious,  the  eyes  dull  and  sunk  in  their  sockets, 
the  appearance  around  them  dark,  and  the  cheeks  exceedingly  pale,  sallow 
or  flushed  in  patches.  The  face  generally  assumes  much  of  the  character 
given  to  it  in  low  fever. 

The  tongue  will  also  guide  us  in  our  opinion.  If  the  mouth  is  moist  and 
clean,  there  cannot  be  much  fever ; but  if  the  tongue  become  loaded  with 
a white  fur,  fever  is  present ; or  if  it  be  coated  with  a dry  brown  sordes, 
that  is  one  indication  of  commencing  exhaustion. 

Vomiting  also  generally  occurs  in  consequence  of  exhaustion  from 
great  exertion,  as  it  often  accompanies  depression  of  the  powers  in  the 
last  stage  of  fever.  The  matter  ejected  from  the  stomach  is  of  the  same 
character  in  both  cases  ; it  is  blackish,  or  has  a coffee-ground  appearance, 
and  it  may  be  fetid.  We  must  discriminate  this  vomiting — as  I have 
before  remarkedf — from  that  which  occurs  at  the  commencement  of 
labour,  dependent  on  the  opening  of  the  os  uteri ; nor  is  it  probable  that 
we  shall  fall  into  a mistake  in  this  particular. 

Shivering  is  another  symptom  of  exhaustion,  when  it  appears  after  many 
hours  of  suffering  have  been  sustained ; and  it  also  indicates  great  local 
injury  either  to  the  pelvic  structures  from  pressure,  or  to  the  uterus  itself. 

Coldness  of  the  extremities,  accompanied  with  clammy  perspiration,  is 
a very  unfavourable  sign  indeed : if  there  be  cold  sweats  over  the  legs, 
arms,  and  neck,  we  may  consider  that  the  patient  is  in  imminent  danger. 

If  delirium  be  present,  we  may  be  perfectly  satisfied  that  there  is  some 
mischief  going  on  either  in  the  uterus,  the  pelvis,  or  the  head ; and  such 
a case  would  require  extreme  care.  We  may,  perhaps,  be  inclined  to 
bleed.  Delivery  will  often  at  once  relieve  this  distressing  symptom. 
Another  state  of  mental  aberration  is  that  of  low  muttering.  The  woman 
lies  quiet,  appears  to  be  talking  constantly  and  rapidly,  but  her  articulation 
is  imperfect ; and  delivery  affords  the  only  chance  of  saving  life  under 
this  state.  These  last  two  symptoms  may  be  regarded  as  most  danger- 


* See  my  father’s  Practical  Observations,  Part  I.  p.  270. 


f Page  92. 


230 


INSTRUMENTAL  LABOUR. 


ous ; they  are  usually  preceded  by  long-continued  wakefulness ; which,  of 
itself,  is  one  of  the  many  proofs  of  exhausted  powers. 

The  fifth  indication  is  the  state  of  the  passages.  If  these  are  moist, 
soft,  cool,  and  not  tender — if  we  can  pass  our  finger  all  round  the  head 
easily,  we  may  be  sure  that  there  is  no  impaction,  and  we  need  not  deliver 
for  their  sake ; but  if  the  parts  become  dry,  hot,  swollen,  and  painful,  so 
that  the  patient  can  scarcely  bear  the  least  touch  upon  them,  then  there 
must  be  injurious  pressure,  and, — to  prevent  sloughing,  we  must  terminate 
the  labour,  though  there  should  be  but  few  of  the  general  symptoms  that 
I have  mentioned ; it  is  seldom,  however,  that  local  injury  exists  in  any 
part  of  the  body  without  the  whole  system  sympathizing.  If  the  patient 
be  robust,  we  may  bleed  from  the  arm ; if  we  cannot  venture  to  take 
blood,  we  may  use  fomentations,  and  endeavour,  by  local  means  of  such 
kind,  to  remove  the  inflammation : and  if  the  case  be  adapted  for  it,  we 
may  have  recourse  to  the  use  of  the  short  forceps.  The  longer  the  pres- 
sure is  continued,  the  worse  will  generally  the  case  become. 

Finally , the  state  of  the  uterine  tumour  becomes  an  indication  for  de- 
livery. If  the  abdomen  be  not  tender  on  pressure,  there  is  no  inflamma- 
tion ; but  if  the  application  of  the  hand  gives  great  pain,  we  have  every 
reason  to  fear  the  approach  of  diseased  action.  There  is  no  question  that 
inflammation  of  the  uterus  itself  may  be  produced  by  a long  continuance 
of  its  excessive  exertion  ; but  as  this  is  usually  accompanied  by  diminished 
power  in  the  general  system,  it  is  seldom  to  be  removed  by  bleeding;  under 
such  a state,  indeed,  it  would  not  be  always  safe  to  abstract  blood  freely: 
delivery  offers  the  only  rational  method  of  relief. 

Summary  of  Symptoms. — If,  then,  the  pains  are  subsiding  gradually,  or 
have  entirely  disappeared, — if  the  strength  is  failing,  the  spirits  sinking, 
the  countenance  becoming  anxious, — if  the  pulse  be  one  hundred  and 
twenty,  one  hundred  and  thirty,  or  one  hundred  and  forty,  in  the  minute, 
— the  tongue  coated  with  a white  slime,  or  dry,  brown,  and  raspy, — if 
there  have  been  two  or  three  rigours, — if,  on  pressing  the  abdomen,  there 
is  great  tenderness  of  the  uterus, — if  there  be  a green  discharge — if  there 
be  preternatural  soreness  of  the  vulva,  with  heat  and  tumefaction  of  the 
vagina — if  the  head  have  been  locked  for  four  hours,  and  made  no  pro- 
gress for  six  01  eight  hours, — if  the  patient  be  vomiting  a dark  coffee- 
ground  like  matter, — if  there  be  hurried  breathing,  delirium,  or  coldness  of 
the  extremities, — then  we  are  at  any  rate  warranted  in  having  recourse  to 
the  forceps,  although  the  labour  have  not  lasted  the  limited  period  of 
twenty-four  hours  or  even  twelve : and  we  should  be  acting  injudiciously 
to  allow  the  case  to  proceed  until  the  four  last-named  symptoms  appear, 
without  relief  being  offered. 


USE  OF  THE  VECTIS. 


231 


But  so  long  as  the  uterus  is  acting  with  energy,  the  strength  and  spirits 
good,  the  countenance  natural  and  cheerful,  the  pulse  under  one  hundred, 
the  tongue  and  mouth  moist  and  clean — so  long  as  there  is  no  vomiting 
nor  rigours,  nor  heat,  swelling,  nor  tenderness  of  parts;  no  green  discharge, 
no  pain  on  pressing  the  abdomen — so  long  as  the  head  retreats  in  the 
absence  and  advances  in  the  presence  of  pain,  provided  there  be  any  pro- 
gress in  the  labour  from  hour  to  hour — so  long  there  can  be  no  necessity 
for  instrumental  aid ; although  the  case  may  have  lasted  considerably  be- 
yond the  specified  limit. 


VECTIS. 


Another  instrument  that  has  been  much  employed  with  the  view  of  ex- 
tracting the  child  living,  is  the  vectis  or  lever  it  consists  of  a single 
blade  ; and*  of  all  the  varieties  that  have  been  fashioned,  Lowder’s  appears 
to  me  to  possess  the  most  useful  form. 

Much  uncertainty  still  hangs  over  the  origin  of  the  vectis;  and  we  are 
without  any  positive  records,  either  regarding  the  real  inventor,  or  the 
precise  time  when  it  was  first  used.  It  is  generally  attributed  to  Roon- 
huysen,  of  Amsterdam,  and  even  now  bears  his  name ; but  I am  inclined 
to  think  that  the  elder  Chamberlen,  who  certainly  introduced  the  modern 
forceps  into  practice,  was  also  the  inventor  of  the  vectis.f  This,  how- 
ever, is  a matter  of  little  importance  in  a practical  point  of  view ; it  is  of 
far  greater  consequence  that  we  should  select  the  best  form  of  instrument, 
provided  we  are  induced  to  trust  it.  It  should  be  twelve  inches  long,  in  a 
straight  line  from  one  extremity  to  the  other,  seven  of  which  should  be 
engrossed  by  the  blade.  The  blade  should  not  spring  from  the  handle  in 
a regular  sweep,  as  is  the  case  with  the  forceps ; but  should  possess  a 
shank,  nearly  straight,  for  the  space  of  three  inches,  retiring  backwards, 
at  a very  small  angle.  The  curve  should  then  commence  gradually,  and 
the  point  should  be  bent  forwards  rather  abruptly.  The  widest  part  of  the 


* I think  both  these  terms  highly  objectionable;  because  if  the  instrument  is  used  as  a lever 
of  the  first  kind,  which  is  that  most  commonly  known  in  mechanics,  we  can  scarcely  avoid 
making  injurious  pressure  on  the  soft  parts  of  the  mother;  and  also  because  the  term  vectis , 
as  employed  by  the  Latins,  carries  with  it  an  idea  of  force  and  violence ; since  that  was  an 
engine  applied  to  raise  great  weights,  wrench  open  doors,  and  perform  other  acts  requiring 
considerable  strength.  The  names  extractor  given  to  it  by  Dease,  and  tractor  by  Blundell, 
are  much  preferable  to  that  of  vectis,  because  they  will  lead  to  a safer  use  of  the  instrument 
in  practice. 

t See  Medical  Gazette,  May  31st,  1831,  p.  305,  et  seq. 


232 


INSTRUMENTAL  LABOUR. 


blade  should  be  near  the  point,  about  one  inch  and  seven-eighths  across, 
and  the  fenestra  should  be  inclined  to  an  oval  shape,  two  inches  and  a 
quarter  long,  and  an  inch  and  one-eighth  broad  in  the  centre ; the  weight 
of  the  instrument  should  be  about  seven  ounces.  The  specimen  delineated 
in  Plate  XXXIV.  fig.  101,  possesses  Saxtorffe’s  hinge;  but  this  is  of  no 
advantage  in  its  use ; it  is  merely  for  the  convenience  of  carriage.  Others 
are  made  with  the  handle  to  unscrew;  and  this  might  lead  to  the  inference 
that  it  was  intended  the  blade  should  be  passed  up  first,  and  the  handle 
screwed  on  afterwards;  such  a mode  of  proceeding,  however,  will  be  found 
inconvenient,  and  seldom  practicable. 

Cases  in  which  the  vectis  is  applicable , and  mode  of  using . — All  the 
cases  in  which  the  short  forceps  are  applicable,  are  supposed  to  be  fitted 
for  the  use  of  the  vectis ; and  the  symptoms  calling  for  its  employment 
are  necessarily  also  the  same.  Three  modes  of  using  this  single  blade 
have  been  suggested; — either  as  a lever  of  the  first  kind,  or  as  an  antago- 
nist to  the  left  hand  introduced  into  the  pelvis,  or  as  a simple  tractor; 
which  last,  indeed,  is  the  only  safe  method.  Chamberlen  and  Roonhuy- 
sen  used  it  as  a lever  of  the  first  kind ; and  they  made  the  pubes  of  the 
mother  form  the  fulcrum.*  I need  not  insist  on  the  mischief  likely  to 
result  from  this  mode  of  acting:  it  is  merely  necessary  that  attention  should 
be  called  to  the  bladder,  placed  directly  behind  the  junction  of  the  pubic 
bones,  to  imagine  the  dangerous  pressure  to  which  it,  as  well  as  the  sur-' 
rounding  structures,  must  be  exposed,  were  we  to  adopt  Roonhuysen’s 
plan.  The  injuries  inflicted,  indeed,  must  have  been  frequent  and  great;' 
and  this  led  Pean,  in  1772,  to  suggest  the  possibility  of  delivering  by  the 
vectis,  without  making  a fulcrum  of  the  mother’s  structures.  He  proposed 
a practice,  which  is  now  sometimes  adopted,  of  grasping  the  shank  of  the 
instrument  with  the  left  hand, — the  outer  edge  of  the  little  finger  being 
applied  towards  the  vulva, — making  that  hand  the  fulcrum,  and  pressing' 
the  extremity  of  the  blade  on  the  child’s  head,  by  raising  the  handle  firmly1 
held  in  the  right  hand.  Though  not  so  easy  a method  of  delivery,  this  is 
much  safer  than  that  first  recommended,  and,  if  used  as  a lever  of  the 
first  kind  at  all , the  instrument  should  be  employed  in  this  mannerf 

Another  mode  practised  was  the  introduction  of  the  instrument  over 
one  side  of  the  head,  and  the  application  of  three  or  four  fingers  of  the  left 
hand  over  the  opposite,  which  were  intended  to  act  as  an  antagonist  to  the 
iron  blade,  and  w7ith  it  to  obtain  a perfect  grasp  of  the  head,  as  the  for- 

* Camper;  “ Remarques  sur  les  Accouchemens,  et  sur  l’Usage  du  Levier  de  Roonhuysen.” 
Mem.  de  I’Academie  de  Chirurgie,  tom.  v.  p.  729. 

+ See  a treatise  by  Ferret,  a Parisian  culler,  in  Descriptions  (les  Arts , ct  dcs  Metiers. 
Paris,  1772. 


Tl.XXXIV 


Zfy.IOO. 


'Ji-  ■ ■ ■ 


s:;  ■ v ..  viiymti pins-v  k 

, - : . ^ - . ■■  v 


' 

library  • Vfc  • wMnmn 

0<t  THE  . ■..  •>  ; ,< 

^ivtasny  or  iumois  ^ , 

■ ■ 

- 


USE  OF  THE  VECTIS. 


233 


ceps  does  ; and  as  the  latter  instrument  is  to  be  regarded  as  a pair  of  arti- 
ficial hands,  so  the  vectis,  if  used  in  this  way,  must  be  looked  upon  as  a 
substitute  for  the  right  hand.  But  it  is  evident  that,  if  there  be  sufficient 
room  in  the  pelvis  to  allow  of  the  introduction  of  three  or  four  fingers, 
over  the  head,  there  can  occur  very  few  cases  in  which  instrumental  assist- 
ance is  necessary.  This  mode  of  using  it  was  first  adopted  by  De  Bruas, 
about  1755* 

In  1783,  Dease  of  Dublin  gave  a new  name  to  the  instrument,  which 
much  influenced  the  mode  of  using  it.  He  called  it  an  extractor , and 
proposed,  that  on  the  point  being  carried  fully  over  the  child’s  head,  the 
handle  should  be  grasped  tightly,  and  held  firmly,  by  one  hand,  while  the 
shank  was  embraced  by  the  other,  and  the  movement,  that  of  steady 
traction  downwards,  should  be  given  by  that  hand  which  embraced  the 
shank,  thus  converting  the  instrument  into  a lever  of  the  third  species. 
He  states  his  opinion,  that  if  used  as  a lever  of  the  first  kind,  it  must 
always  prove  highly  dangerous,  “ retentions  of  urine  being  the  immediate, 
and  involuntary  discharge  of  urine  the  lasting  consequences  of  it.”f  The 
mode  recommended  by  Dease  is  that  now  generally  adopted — that  which 
I would  advise  the  young  practitioner  to  follow,  provided  he  be  inclined 
to  call  in  the  aid  of  the  vectis. 

This  instrument,  consisting  of  only  one  blade,  and  being  very  easily 
introduced,  has  often  been  employed  clandestinely,  and  without  the  know- 
ledge either  of  the  patient  or  her  friends  ; and  Lowder,  as  one  of  the  argu- 
ments in  its  favour,  brought  forward  the  facility  with  which  it  could  be 
used,  as  a means  of,  terminating  the  delivery  secretly.  It  is  not  possible, 
in  my  opinion,  to  offer  any  better  reason  for  discarding  this  instrument 
from  practice,  than  that  insisted  on  by  Lowder  as  one  of  its  chief  recom- 
mendations; for  in  this  age,  if  any  man  accustoms  himself  to  use  the  vec- 
tis, or  any  other  obstetric  power  clandestinely,  such  interference  must  in 
the  end  lead  to  disgrace  and  bitter  self-reproach.  In  regard  to  the  vectis, 
then,  we  should  act  exactly  as  with  the  forceps — inform  the  patient  and 
her  friends  of  the  necessity  of  assistance  being  rendered,  and  never  inter- 
fere unless  circumstances  demand  our  aid.  Before  the  introduction  of 
the  instrument,  the  bladder  must  be  emptied  by  the  catheter,  and  the  rec- 
tum unloaded  also,  if  requisite.  The  same  posture  must  be  adopted  as 
previously  recommended  : the  patient’s  person  must  be  brought  conve- 


* The  Practice  of  Using  the  Spoon  Restored,  with  a Short  Account  of  other  instruments 
employed  in  Midwifery,  Bj^  J.  H.  De  Bruas,  Middleburgh,  1755;  in  the  Dutch  language. 

t Observations  in  Midwifery,  particularly  on  the  Method  of  Delivery  in  Difficult  Labours. 
Introduction,  p.  6. 

30 


234 


INSTRUMENTAL  LABOUR. 


niently  near  to  the  edge  of  the  bed,  and  the  instrument  warmed  and 
greased.  Two  fingers  of  the  left  hand  are  then  to  be  passed  as  high  as 
possible  within  the  vagina,  over  the  child’s  head ; the  handle  of  the  instru- 
ment must  be  held  tightly  in  the  right,  and  depressed  sufficiently  low  to 
allow  the  point  to  slide  up  between  the  fingers  and  the  head.  The  same 
kind  of  semi-rotatory  motion  recommended  in  the  application  of  the  for- 
ceps, will  also  facilitate  the  introduction  of  the  vectis;  and,  as  with  the 
forceps,  if  any  impediment  occur  to  its  easy  passage,  that  must  not  be 
overcome  by  main  force,  but  a different  direction  must  be  given  to  the 
blade,  and  the  obstacle  must  be  surmounted  by  gentle  insinuation.  On 
the  complete  introduction  of  the  instrument,  the  fingers  of  the  left  hand 
are  to  be  withdrawn,  and  the  shank  so  grasped  with  that  hand,  lhat  the 
little  finger  shall  lie  near  the  os  externum,  and  the  first  finger  surround  the 
junction  of  the  handle  with  the  blade.  Plate  XXXIV.  fig.  102.  Thus  a 
firm  purchase  is  obtained  ; and  the  whole  instrument  must  be  steadied  with 
the  right  hand,  while  traction  is  made  with  the  left.  The  extractive  power 
must  not  be  a constant,  strong,  uninterrupted  pull,  but  must  consist  of  a 
number  of  short,  steady,  firm,  extractive  efforts,  following  each  other  in 
tolerably  quick  succession ; the  left  hand  pressing  strongly  against  the 
shank  under  each,  so  that  the  point  may  at  the  same  time  compress  the 
head,  while  the  handle  remains  stationary.  Here  also,  as  with  the  for- 
ceps, we  must  work  during  the  continuance  of  contraction,  and  desist  in 
its  interval ; and  should  the  uterus  be  inert,  we  must  imitate  nature,  making 
our  traction  only  occasionally.  This  instrument  is  much  more  likely  to 
lose  its  hold  than  the  forceps ; but  as  it  is  easily  re-introduced,  and  as 
there  is  no  second  blade  to  adjust,  that  occurrence  is  of  little  conse- 
quence. 

In  employing  the  vectis,  then,  we  shall  find  it  necessary  to  apply  it  over 
different  parts  of  the  cranium,  successively,  in  order  to  relieve  the  head 
from  its  fixed  situation,  and  favour  its  descent ; and  we  may  sometimes 
feel  it  necessary  to  use  it  one  minute  as  a tractor,  and  the  next  as  a lever; 
being,  however,  most  cautious  to  make  the  fulcrum  of  our  own  left  hand , 
as  first  recommended  by  Pean.  The  occiput,  and  the  projection  behind 
the  ear,  answering  to  the  site  of  the  mastoid  process,  will  offer  the  best 
position  for  the  application  of  the  instrument’s  point. 

The  relative  value  of  the  vectis  and  forceps  as  obstetrical  assistants  has 
been  the  subject  of  much  controversy.  Some  practitioners  invariably  used 
the  vectis — as  Bland,  Lowder,  Dennison,  and  Sims;  others  gave  the  pre- 
ference to  the  forceps,  among  which  number  were  Smellie,  Denman, 
Osborn,  and  Hamilton ; of  the  present  teachers,  I believe  most  are  in  the 


RELATIVE  VALUE  OF  VECTIS  AND  FORCEPS. 


habit  of  employing  the  latter.*  We  must,  however,  receive  the  recom- 
mendations even  of  practical  men  on  this  subject  cum  grano  salis ; we 
must  recollect  that  early  instruction  is  likely  to  prejudice  every  one  in 
favour  of  any  particular  instrument,  and  that  a certain  degree  of  acquired 
dexterity  in  its  use  would  probably  attach  him  to  it,  and  cause  him  to 
recommend  it.  Thus,  then,  although  one  practitioner  may  wield  the  for- 
ceps, and  another  the  vectis,  with  the  greatest  advantage,  it  by  no  means 
follows,  either  that  his  pupils  should  be  able  to  administer  artificial  aid 
with  the  same  success,  or  that  they  should  find  the  superiority  of  one 
instrument  so  decidedly  outweigh  that  of  the  other,  as  they  might  be  led 
to  imagine  if  they  listened  to  the  doctrines  of  those  practised  exclusively 
in  the  employment  of  either.  If,  however,  it  can  be  shown,  by  legitimate 
arguments,  that  the  one  instrument  possesses  a decided  advantage  over 
the  other,  we  are  bound  to  use  that  means  which  offers  the  fairest  pro- 
spect of  success ; until,  indeed,  by  actual  experience,  we  become  convinced 
of  the  fallacy  of  our  previous  impressions. 

Arguments  in  favour  of  the  vectis. — The  arguments  in  favour  of  the 
vectis  are,— first,  that  there  being  but  one  blade,  it  is  more  easily  applied; 
and  that  as  the  greatest  difficulty  in  introducing  the  forceps  consists  in 
adjusting  the  second  blade,  that  inconvenience  is  of  course  obviated. 
Secondly,  that  extraction  can  be  more  easily  effected  with  it.  Thirdly , 
that  being  so  easily  applied,  it  is  not  necessary  for  the  operator  to  ascer- 
tain so  intimately  the  nice  obstetrical  points  connected  with  the  case,  or 
to  make  himself  so  minutely  acquainted  with  the  position  of  the  head,  as 
when  the  forceps  are  used.  Fourthly,  that  it  can  be  used  in  cases  where 
the  short  forceps  are  perfectly  inadmissible — before  the  head  has  descended 
sufficiently  low  for  us  to  feel  an  ear ; because  we  do  not  guide  this  instru- 
ment over  the  ear,  but  introduce  it  where  we  can  most  easily  apply  it, 
and  where  we  can  obtain  the  most  useful  purchase. 

Each  of  these  arguments  deserves  a distinct  consideration.  In  the 
first  place,  I would  readily  grant  that  the  single  instrument  can  be  more 
easily  applied  than  the  two-bladed  forceps ; but  I cannot  accede  to  the 
proposition  that  delivery  can  be  more  easily  effected  with  it — at  least  it  is 
not  so  in  my  hands.  I am  not  arrogating  too  much  to  myself  when  I say 
that  I have  had  some  considerable  experience  in  instrumental  cases ; I 
can  conscientiously  affirm  that  I entered  on  practice  quite  unprejudiced 
as  to  the  relative  merits  of  the  two  instruments ; and  I have  found  it,  in 


* One  of  the  first  celebrated,  and  perhaps  the  most  strenuous,  of  all  the  advocates  in  this 
country,  for  the  vectis  as  the  preferable  instrument,  was  Dr.  Bland.  His  arguments  will  be 
found  in  a paper  by  him,  published  in  the  second  volume  of  the  London  Medical  Communica- 
tions,  in  the  year  1790,  p.  397, 


236 


INSTRUMENTAL  LABOUR. 


no  few  instances,  easy  to  deliver  by  means  of  the  forceps,  when  I had  made 
trial  of  the  vectis  without  effect.  If  such  has  been  the  case — as  I have 
reason  to  believe  it  has — with  others  as  well  as  myself,  of  what  use  is  it 
to  boast  the  easy  adaptation  of  a power  which,  when  properly  adjusted, 
is  so  inadequate  to  the  end  proposed  ? — Again,  we  are  told  that,  being  so 
much  more  easily  applied  than  the  forceps,  it  is  not  necessary  that  the 
operator  should  be  so  perfectly  conversant  with  obstetrical  principles  in 
general,  or  the  particular  points  of  the  case  under  treatment.  This, 
although  a very  specious,  is,  in  my  opinion,  the  most  injudicious  and 
untenable  argument  which  could  possibly  be  adduced  in  favour  of  this 
instrument: — to  prefer  the  vectis  because  in  may  be  worked  by  a person 
who  knows  but  little  of  obstetric  principles,  is,  to  say  the  least  of  it, 
placing  a dangerous  instrument  in  rash  hands,  framing  an  excuse  for 
ignorance,  and  opening  a wide  door  for  violence  and  injury.  I cannot 
but  think  that  man  highly  culpable  who  would  attempt  to  introduce  the 
vectis  without  knowing  minutely  the  bearings  of  the  case  under  his  care, 
or  who  was  not  sufficiently  acquainted  with  the  principles  of  obstetric 
science  to  enable  him  properly  to  adapt  the  forceps.  Such  a man  would 
compromise  his  patient’s  safety,  to  say  nothing  of  his  own  character. 
The  fourth , and  last,  is  the  only  argument  which  with  me  carries  any 
weight  in  support  of  the  vectis — that  it  can  be  used  in  cases  where  the 
short  forceps  is  inadmissible,  owing  to  the  principal  bulk  of  the  head 
remaining  above  the  pelvic  brim : it  is  a longer  instrument,  and  in  its 
application  passes  higher  within  the  woman’s  person  than  the  short  for- 
ceps, being  received  somewhat,  indeed,  into  the  cavity  of  the  uterus  itself ; 
but  to  overcome  the  difficulty  of  such  a case,  we  are  in  possession  of  a 
much  more  efficient,  and,  in  my  opinion,  even  more  safe  instrument,  in 
the  long  forceps  : so  that  either  with  the  long  or  the  short  forceps  we  may 
surmount  all  the  impediments  to  which  the  vectis  is  applicable,  under 
vertex  presentation. 

Positive  advantages  of  the  forceps. — Besides  these  negative  advantages, 
the  forceps  appear  to  me  positively  superior  to  the  vectis  in  many  respects. 
First,  when  we  have  applied  the  blades  fully  over  the  ears,  we  can  gene- 
rally turn  the  head  into  that  direction  most  convenient  for  its  exit.  It  has 
been  already  shown  that  if  the  face  be  coming  forward,  towards  one  or 
other  groin,  we  may,  perhaps,  find  it  necessary  to  turn  it  into  the  hollow 
of  the  sacrum  before  we  can  accomplish  extraction,  and  that  this  turn  can 
be  effected  with  no  very  great  difficulty ; but  we  cannot  do  this  with  the 
vectis — we  can  only  extract  the  head  in  that  situation  under  which  it  is 
attempting  the  passage.  Secondly , we  can  compress  the  head  with  the 
forceps,  and  diminish  its  lateral  diameter  so  as  to  enable  it  to  escape 
through  a somewhat  contracted  aperture.  It  may  be  answered,  that  this 


POSITIVE  ADVANTAGES  OF  FORCEPS.  237 


can  be  effected  with  the  vectis  also ; but  when  the  head  is  compressed 
between  the  two  blades  of  the  forceps,  the  pressure  is  taken  off  from  the 
mother’s  structures ; should  the  vectis,  however,  be  employed,  the  coun- 
ter-pressure is  made  by  the  bony  pelvis  itself,  and  the  soft  parts  lying 
between  the  head  and  the  pelvic  bones  must  suffer  more  or  less  from  con- 
tusion. Thirdly,  we  are  not  in  so  much  danger  of  injuring  the  mother, 
because,  with  the  forceps,  we  have  a fixed  fulcrum,  and  consequently 
there  is  no  necessity  for  us  to  form  one  for  ourselves.  To  this  observa- 
tion, again,  it  may  be  answered  that  the  instrument  should  be  used  as  an 
extractor,  and  not  as  a common  lever;  and  that  therefore  our  argument 
is  unfair,  as  being  deduced  from  an  abuse  of  means.  In  reply,  I would 
observe,  that  the  instrument  is  so  much  more  easily  used  as  a lever  of  the 
first  than  of  the  third  species,  and  the  fulcrum  is  so  much  more  naturally 
made  by  the  bony  pelvis  than  her  own  hand,  that  in  our  anxiety  to  accom- 
plish our  object, — however  determined  we  may  be  to  the  contrary, — we 
run  a great  risk  of  transgressing  the  rule,  and  endeavouring  to  scoop  the 
head  out.  It  will,  of  course,  be  understood  that  these  remarks  apply  to 
young  operators,  and  not  to  experienced  practitioners. 

These  three  principal  advantages,  then,  of  the  forceps — the  being  able 
to  turn  the  head  in  any  direction, — their  producing  compression  and 
diminution  of  bulk,  without  bruising  the  soft  parts,  and  the  comparative 
safety  with  which  they  may  be  employed — induce  me  to  use  them,  and 
strongly  recommend  them,  in  preference  to  the  vectis.  There  are  only 
three  cases  in  which  I think  the  latter  instrument  preferable ; under  pre- 
sentations of  the  brow,  face,  or  side  of  the  head — the  ear,  for  example. 
In  brow  presentations  the  instrument  may  sometimes  be  advantageously 
used — being  passed  over  the  occiput — to  bring  down  the  vertex,  and 
prevent  the  case  being  converted  into  a face  presentation ; but  this  is 
seldom  requisite,  and  can  only  be  effected  before  impaction  has  occurred : 
and  where  the  face  presents,  and  the  head  has  become  impacted  in  the 
pelvis,  the  case  is  more  likely  to  be  easily  terminated  by  the  adaptation  of 
the  vectis,  as  shown  in  Plate  XXXIY.  fig.  102,  than  by  the  forceps:  and 
the  same  remark  holds  good  in  regard  to  presentations  of  the  side  of  the 
head,  Plate  XXX.  fig.  91. 


238 


INSTRUMENTAL  LABOUR. 


FILLET. 


The  fillet  or  lacque — an  instrument  now  very  properly  discarded  from 
practice  in  head  presentations — deserves  but  very  little  consideration. 
The  first  mention  of  such  a contrivance  occurs  in  the  writings  of  Rhazes,# 
about  the  end  of  the  ninth  century,  and  became  known  under  the  name 
laqueus.  It  consists  of  a strip  of  strong  cloth,  silk,  or  leather,  formed  into 
a running  noose,  and  was  sometimes  sewn  up  like  an  eel-skin,  open  at 
both  ends,  to  admit  the  introduction  of  a piece  of  whalebone,  cane,  or  wire, 
throughout  its  entire  length,  by  which  its  application  might  be  facilitated. 
It  was  intended  to  be  introduced  over  the  head  in  whatever  way  was 
most  easily  accomplished ; and  this  done,  the  cane  was  to  be  withdrawn, 
the  loop  tightened,  and  extraction  was  to  be  effected  by  main  force.  We 
cannot  suppose  that  the  fillet  could  retain  its  hold  unless  it  was  actually 
passed  over  the  chin,  or  round  the  neck  ; and  if  fixed  in  the  latter  position, 
it  is  very  evident  that  the  traction  would  have  a tendency  to  double  the 
neck  upon  itself,  to  turn  the  head  to  one  side,  and  to  form  a most  difficult 
and  complicated  case  out  of  one  which  might,  perhaps,  have  been  termi- 
nated by  the  efforts  of  nature  alone ; because  the  power  obtained  could 
only  be  employed  in  one  direction,  and  that  in  a straight  line  down- 
wards.f 

* Smellie’s  Midwifery,  Introduction,  p.  xxxiii, 

t I have  never  personally  known  this  invention  applied  to  facilitate  a lingering  labour ; 
and  I believe  the  last  time  it  was  used  in  London  is  recorded  by  my  friend,  Dr.  Merriman, 
(Synopsis,  p.  289,)  in  a case  where  his  uncle  was  an  unwilling  spectator  of  the  highest  degree 
of  violence  inflicted  by  this,  instrument,  in  the  hands  of  a French  physician.  The  force; 
employed  on  that  occasion  was  so  great,  that  the  head  was  severed  from  the  body,  and  the 
poor  woman,  as  might  be  expected,  died  on  the  secbnd  day  after  delivery.  Smellie  gives  a1 
plate  of  what  he  considers  the  best  specimen  of  the  fillet,  communicated  to  him  by  Dr.  Mead;  and 
states,  that  it  may  be  employed,  provided  the  forceps  are  not  at  hand.  In  this  recommenda- 
tion Smellie  must  have  merely  followed  the  fashion  qf  the  day;  for  his  consummate  know- 
ledge of  the  mechanism  of  parturition  taught  him  that  such  a contrivance  could  not  be 
introduced  if  the  head  was  impacted  in  the  pelvis ; and  he  was  aware,  also,  that  even  if 
adjusted  in  the  most  fortunate  manner,  it  could  not  favour  the  necessary  turns,  but  was 
merely  calculated  to  act  on  the  application  of  brute  force. — Vide  Treatise  on  Midwifery,  vol. 
i.  p.  218.  It  is  worthy  of  remark  also,  that  Smellie  neither  delineates  nor  speaks  of  the  vectis 
in  any  part  of  his  works  ; by  which  we  may  infer  he  considered  it  so  dangerous,  that  he 
desired  it  should  be  banished  from  the  list  of  obstetrical  instruments  altogether.  This  must 
appear  strange  when  we  consider  his  sanction  of  the  fillet,  which  is,  without  doubt,  both 
much  more  difficult  in  its  application  than  the  vectis,  and  much  more  hazardous  in  its  use. 


LONG  FORCEPS. 


239 


LONG  FORCEPS. 

One  of  the  most  valuable  instruments  employed  in  midwifery,  under  care- 
ful management,  is  the  long  forceps,  if  formed  according  to  the  shape 
and  proportions  represented  in  Plate  XXX Y.  fig.  103,  and  used  in  those 
cases  to  which  it  is  particularly  appropriate;  for  although  it  must  cer- 
tainly be  regarded  as  more  capable  of  inflicting  injury  than  the  shorter 
kind,— inasmuch  as  it  is  introduced  higher  within  the  woman’s  person, 
and  its  extremities  are  actually  received  somewhat  into  the  cavity  of  the 
uterus  itself, — still  its  powers  and  capabilities  are  such  as  frequently  to 
render  it  a substitute  for  the  horrible  operation  of  craniotomy.  This  value 
I have  myself  often  experienced ; for  I have  extracted  many  children  alive 
by  the  agency  of  the  long  forceps,  who  had  been  doomed  to  death  by 
other  parties,  and  who  must  have  been  sacrificed,  to  preserve  the  mother, 
unless  we  had  possessed  this  instrument. 

Although,  however,  the  long  forceps  form  so  useful  an  addition  to  our 
obstetric  powers,  they  were  not  generally  adopted  by  practical  men  till 
about  the  commencement  of  the  present  century.  Smellie,  indeed,  con- 
trived a pair  much  longer  than  his  common  instrument,  but  he  considered 
them  so  dangerous  in  use,  that  he  hesitated  to  recommend  them,  and  did 
not  even  display  them  in  his  lectures.  Smellie,  however,  as  will  be  shown, 
applied  their  blades  in  a very  different  manner  from  that  which  is  now 
usually  practised,  and  which  I myself  follow. 

Description. — The  instrument  which  I have  formed  for  my  own  use, 
and  recommend  to  the  practitioner,  measures,  from  the  extreme  of  the 
handle  to  the  tip,  twelve  inches  and  three  quarters,  of  which  four  inches 
and  a quarter  from  the  handles,-  and  eight  and  a half  the  blades,  being  one 
inch  and  a half  longer  in  the  blade  than  the  short  forceps,  and  a quarter 
of  an  inch  longer  in  the  handles.  The  greatest  width  between  the  blades 
is  about  their  centre,  and  measures  two  inches  and  seven  eighths ; the 
points  are  an  inch  asunder.  It  weighs  twelve  ounces  and  a quarter. 
From  the  handles,  two  parallel  straight  shanks  arise,  of  an  inch  and  a 
half  in  length  ; and  it  is  in  the  addition  of  this  shank  that  the  instrument 
differs  principally  from  the  curved  forceps  of  Osborn,  the  curve  of  the 
blades  springing,  not  from  the  handles,  but  from  the  extremity  of  the 
shank.  The  object  of  this  addition  is  to  prevent  laceration  of  the  peri- 
neum, in  the  use  of  the  instrument;  for  if  the  long  forceps  of  Smellie  or 
Haighton  be  employed,  in  which  the  curve  takes  its  origin  from  the  handle 
itself,  the  mother’s  structures  at  the  outlet  of  the  pelvis  must  necessarily 


240 


INSTRUMENTAL  LABOUR. 


be  pressed  upon  unequally  by  the  commencement  of  the  blades,  before  the  j 
head  has  descended  low  enough  to  distend  them  uniformly  ; and  thus  great 
danger  of  injury  must  ensue.  In  choosing  an  instrument,  as  remarked  in 
regard  to  the  short  forceps,  we  must  be  particular  that  the  internal  sur- 
face of  the  limb  of  each  blade  is  slightly  convex ; and  the  joint  should  be 
loosely  formed,  so  that  the  handles,  when  locked,  should  be  allowed  a 
considerable  play  upon  each  other  laterally. 

The  instrument,  delineated  in  Plate  XXXV.  fig.  103,  possesses  a slight 
lateral  curve ; and  although  I prefer  a straight  short  forceps , I think  the 
curve  a useful  addition  to  the  long  kind.  In  the  adaptation  of  these 
blades,  there  is  not  so  much  risk  that  we  should  apply  them  wrongly,  as 
when  we  use  the  curved  short  pair;  for  as  they  are  always  to  be  intro- 
duced in  reference  to  the  pelvis,  and  not  to  the  particular  position  of  the 
head,  we  cannot  well  mistake  which  blade  is  to  be  passed  uppermost. 

State  of  the  parts  requisite  for  its  introduction. — As  I have  already 
mentioned  that  the  points  of  this  instrument  are  passed  within  the  os  uteri, 
the  student  will  at  once  perceive  that  it  cannot  be  used  if  the  mouth  of  the 
womb  be  undilated,  especially  if  it  be  rigid:  for  although  we  might  be 
able  to  insert  each  blade  separately,  still,  when  they  are  closed,  the  two 
handles  cannot  be  brought  near  each  other  without  the  os  uteri  being 
pressed  upon,  bruised,  and  perhaps  lacerated.  It  would  be  too  strong  a 
position,  to  lay  it  down,  as  a general  rule,  that  that  organ  should  be  en- 
tirely dilated  before  the  instrument  is  had  recourse  to : — to  such  a degree, 
indeed,  that  we  shall  not  be  able  to  feel  the  least  part  of  its  disc  ; because! 
there  are  a great  many  cases  in  which  it  is  pinched  between  the  head  of 
the  child  and  some  points  of  the  pelvic  bones,— is  prevented  from  full  dila- 
tation, by  being  held  prisoner,  as  it  were,  by  this  pressure, — and,  conse- 
quently, in  which  a great  portion  of  its  substance, — both  anteriorly.^ 
towards  the  pubes,  and  posteriorly,  towards  the  promontory  of  thcj 
sacrum,— can  be  easily  distinguished  by  the  finger ; while  at  the  sides  of 
the  pelvis  it  is  perfectly  soft,  flaccid,  and  distensible,  and  quite  out  of  the 
reach  of  a common  examination.  The  rule  which  I have  been  in  the| 
habit  of  following  in  my  own  practice  is,  that  if  one-third  of  the  os  uteri1 
can  be  felt  continuously,  it  is  most  likely  in  a state  that  will  not  admit  the 
safe  action  of  the  instrument. 

Cases  in  which  serviceable.— The  cases  in  which  this  instrument  is  so; 
particularly  serviceable  are,  where  the  head  has  partly  engaged  in  the 
pelvic  brim,  having  descended  too  low  to  be  raised  for  the  introduction  of 
the  hand  into  the  uterus,  and  the  performance  of  the  operation  of  turning,  | 
while  at  the  same  time  it  has  not  entered  the  cavity  sufficiently  for  us  to  | 
feel  an  ear,  and  where  delivery  has  become  necessary  either  in  conse- 
quence of  haemorrhage,  convulsions,  syncope,  or  any  other  accidental 


APPLICATION  OF  LONG  FORCEPS. 


241 


cause; — the  os  uteri  being  at  the  same  time  perfectly  dilated,  or  most 
easily  dilatable.  But  it  is  especially  useful  in  those  instances  where  the 
pelvis  is  slightly  contracted  in  its  conjugate  diameter,  measuring  between 
the  pubes  and  the  sacrum  but  a little  more  than  three  inches ; — where  the 
principal  bulk  of  the  head  remains  above  the  brim, — the  uterine  energies 
being  strongly  exerted,  perhaps,  but  not  powerful  enough  to  squeeze  the 
foetal  skull  through  the  .diminished  aperture ; — in  which  either  exhaustion 
is  approaching,  or  there  exists  a well-grounded  fear  that  the  uterus  may 
injure  itself  by  the  violence  of  its  own  expulsive  efforts.  In  such  a case, 
provided  the  os  uteri  is  completely,  or  almost  fully  opened,  with  the  vagina 
and  perineum  sufficiently  distensible,  the  long  forceps  may  be  had  recourse 
to, — sometimes  with  decided  advantage, — and  may  render  the  horrifying 
operation,  entailing  the  destruction  of  the  child’s  life,  unnecessary. 

Mode  of  application. — The  mode  of  applying  the  instrument  differs  ex- 
ceedingly from  that  adopted  when  the  short  forceps  are  used.  We  do  not 
apply  it  in  relation  to  the  situation  of  the  child’s  head,  but  to  the  points  of 
the  pelvis.  I have  already  mentioned  that  we  adapt  the  short  forceps 
decidedly  in  relation  to  the  situation  of  the  head,  because  we  introduce 
each  blade  over  an  ear;  but,  in  using  the  longer  instrument,  we  apply  a 
blade  within  each  ilium.  The  woman,  then,  lying  on  her  left  side,  the 
one  blade  will  be  above,  the  other  below ; and  whether  the  child’s  face 
be  directed  towards  the  right  or  the  left  side,  one  is  placed  over  the  fore- 
head, and  the  other  over  the  occiput;  or  rather  the  blades  are  found  to  be 
applied  somewhat  diagonally,  one  reaching  to  the  upper  part  of  the  orbit, 
— just  to  the  superciliary  ridge, — and  the  other  exactly  opposite  to  it,  on 
one  side  of  the  occiput.*  Plate  XXXV.  fig.  104. 

* The  first  recommendation  which  Smcllie  gave  was,  that  the  blades,  like  those  of  the  com- 
mon  instrument,  should  be  adapted  over  the  ears — one  lying  behind  the  pubes,  and  the  other 
anterior  to  the  sacral  promontory ; and  in  this  recommendation  he  has  been  followed  by  Burns, 
(fifth  edition,  p.  441,)  Baudelocque,  (parag.  1806 — Heath’s  Translation,)  Dewees,  (System  of 
Midwifery,  p.  324,)  and  other  practitioners  of  repute;  though  both  the  latter-named  authors 
prefer  turning,  if  practicable,  to  the  use  of  the  long  forceps.  But  he  advises,  also,  “if  the  ope- 
rator finds  the  upper  part  of  the  sacrum  jutting  in  so  much  that  the  point  of  the  forceps  can- 
not pass  it,  let  him  try  with  his  hand  to  turn  the  forehead  a little  backwards,  so  that  one  ear 
will  be  towards  the  groin,  and  the  other  towards  the  side  of  that  prominence;  consequently 
there  will  be  no  more  room  for  the  blades  to  pass  along  the  ears;  but  if  the  forehead  should 
remain  immoveable,  or,  though  moved,  return  to  its  former  place,  let  one  blade  be  introduced 
lehind  one  ear,  and  its  fellow  before  the  other.” — (Treatise  on  Midwifery,  vol.  i.  p.  238.)  This 
quotation  from  Smellie  imbodies  the  opinion  and  practice  of  his  followers,  and  proves  how  in- 
timately versed  that  great  physician  was  with  the  difficulties  sometimes  met  with  in  obste- 
tric surgery.  The  truth  is,  that  in  by  far  the  greater  number  of  cases  under  which  the  long 
forceps  become  necessary  and  useful,  it  is  impossible  to  apply  them  over  the  ears,  in  conse- 
quence  of  this  very  impediment  which  Smellie  has  pointed  out;  the  extremity  of  that  blade 
which  is  introduced  backwards  impinges  on  the  promontory  of  the  sacrum,  and  neither  force 
nor  address  will  overcome  the  resistance  offered  to  its  progress  upwards.  When  the  pelvis  is 

31 


242 


INSTRUMENTAL  LABOUR. 


To  M.  de  Leurie,  a French  physician  of  some  eminence,  we  are  in- 
debted for  having  first  suggested  the  propriety  of  adapting  the  blades  to 
the  forehead  and  occiput.  In  a small  work  on  the  Csesarean  section,  and 
the  application  of  the  forceps  when  the  head  is  detained  above  the  pelvic 
brim,  published  in  1779,  he  strongly  advises  this  method  of  proceeding. 

Two  objections  against  this  mode  were  urged  by  Baudelocque ; and  the 
merits  of  the  new  suggestion  canvassed  neither  very  fairly  nor  very  tem- 
perately. He  objects,  that  if  the  blades  “ be  placed  at  the  sides  of  the 
pelvis,”  they  must  be  applied  over  the  face  and  occiput,  and  that  there  is 
consequently  great  danger  to  the  infant’s  features ; — and  again,  he  argues 
that  if  pressure  be  used  in  that  direction,  the  bulk  of  the  head  cannot  be 
diminished  in  the  lateral  diameter,  (where,  indeed,  such  diminution  is  re- 
quired,) but  its  width  must  actually  be  augmented ; because  “ the  head 
being  compressed  one  way,  it  must  be  lengthened  in  the  other.”*  With 
regard  to  the  first  of  these  observations,  it  is  founded  on  an  erroneous  idea 
regarding  the  actual  position  and  form  of  the  foetal  head : he  seems  to  have 
overlooked  the  very  large  proportion  which  the  cranium,  properly  so 
called,  bears  to  the  face  in  the  mature  foetus,  and  to  have  forgotten  that 
under  labour  the  chin  is  generally  thrown  forcibly  upon  the  chest,  the 
head  therefore  bent  very  much  forwards,  while  the  vertex  becomes  the  most 
depending  part : in  consequence  of  which  position,  the  forehead,  and  not 
the  face,  would  principally  bear  the  stress  of  pressure.  Besides,  even 
allowing  that  the  blades  were  long  enough  to  cover  the  face  entirely,  pro- 
vided both  are  of  the  same  dimensions,  the  point  of  that  which  is  applied 
over  the  occiput  would  impinge  on  the  neck  of  the  child,  and  prevent  the 
other  passing  up  so  high  as  to  embrace  the  face ; if  otherwise,  they  could 
not  be  properly  locked.  Even  in  the  most  recent  works,  however,  on  ob- 
stetric science,  we  read  of  the  injury  likely  to  be  done  to  the  child’s  face 
by  the  forceps,  used  as  I recommend  them ; and  by  some  authorsf  we  are 
instructed  that  the  blade  applied  over  the  face  should  be  softly  padded,  as 
a protection  to  the  features.  I have  employed  this  instrument  on  very 
numerous  occasions,  and  I never,  to  my  recollection,  bruised  a single  fea- 
ture. In  general,  the  point  of  the  instrument  has  not  ascended  farther  than 
the  eye-brow,  or  (if  the  head  were  transversely  placed,  instead  of  diago- 
nally) than  the  root  of  the  nose. 

The  second  objection  is  not  more  difficult  to  dispose  of  than  the  first, 


well  formed,  indeed,  and  the  necessity  for  having-  recourse  to  the  long  forceps  originates  in 
any  of  the  accidental  causes  just  named,  it  may  be  very  possible,  and  even  easy,  to  apply  them 
as  Smellie,  Baudelocque,  Burns,  and  Dewees,  advise;  but,  under  a contracted  state  of  the  con. 
jugate  diameter  at  the  brim,  it  is  very  seldom  that  this  is  practicable. 

* Parag.  1801,  translation, 
t Campbell’s  Midwifery,,  p.  212, 


APPLICATION  OF  LONG  FORCEPS. 


243 


for  it  is  founded  on  a false  assumption.  There  is  no  question  that  the  foetal 
head  cannot  be  decreased  in  one  diameter  without  being  lengthened  in 
another ; but  it  does  not  necessarily  follow  that  under  the  application  of 
the  long  forceps,  the  increased  capacity  should  be  from  one  parietal  bone 
to  the  opposite.  It  will  be  found,  indeed,  in  practice,  that  the  increase 
principally, — if  not  entirely, — takes  place  in  the  direction  from  the  chin 
to  the  vertex ; and  that  the  cranium  is  moulded  into  a still  longer  or  more 
conical  form.  Now,  as  this  particular  change  in  the  figure  of  the  head 
does  not  in  the  least  interfere  with  its  passage  through  the  pelvis,  the 
only  consideration  which  presses  itself  on  the  mind  is,  whether  it  is  likely 
to  endanger  the  child’s  life ; and  I myself  suspect,  from  observation,  that 
the  foetus  will  not  bear,  with  impunity,  the  same  degree  of  pressure  when 
the  compressing  powers  are  adapted  over  the  forehead  and  occiput,  as 
when  applied  laterally : — but  this  requires  farther  confirmation.* 

I will  take,  then,  the  case  most  frequently  met  with  in  illustration,  and 
suppose  the  patient  possesses  a slightly  contracted  pelvis.  I will  presume 
that  the  parts  are  tolerably  well  relaxed;  that  the  os  uteri  is  dilated, being 
not  discoverable  at  the  sides,  but  pinched  anteriorly  between  the  head  of 
the  child  and  the  pelvic  bones,  tender  and  slightly  swollen ; that  a large 
portion  of  the  head  has  come  into  the  pelvis  in  an  elongated,  conical 
shape,  but  that  the  base  remains  above  the  brim ; that  eighteen  or  twenty- 
four  hours  have  elapsed  since  the  rupture  of  the  membranes ; that  the 
pains,  which  have  been  exceedingly  strong,  are  beginning  to  flag,  and 
that  other  symptoms  of  exhaustion  are  appearing : — or  perhaps  that  they 
still  continue  powerful,  but  that  there  has  supervened  a violent  local  pain 
at  one  particular  part  of  the  uterus,  constant  and  uninterrupted ; so  that 
we  have  reason  to  fear  injury  to  its  structure  may  occur,  unless  delivery 
be  speedily  accomplished:  under  such  a state,  if  the  pelvis  contains  more 
than  three  inches  in  the  conjugate  diameter,  and  is  not  diminished  in  space 
laterally,  we  are  warranted  in  having  recourse  to  the  long  forceps,  and 
the  operation  must  be  conducted  in  the  following  manner. 

The  woman  being  placed  on  her  left  side,  with  the  nates  near  the  edge 
of  the  bed, — the  bladder  being  evacuated  by  the  catheter,  and  the  rectum 
being  emptied  also,  if  necessary, — we  warm  and  grease  both  blades  of 
the  instrument,  and  pass  two  fingers  of  the  left  hand  under  the  right  ilium, 
as  high  as  possible  upon  the  child’s  head ; then,  taking  lightly  in  our  right 
hand  that  blade  whose  convex  edge  is  towards  our  left  side  when  the 
back  of  the  instrument  is  next  our  person, f we  incline  the  handle  up  to- 
wards the  pubes,  and  introduce  the  point  backwards  along  the  sacrum, 

* See  Radford’s  second  Essay  on  Midwifery,  p.  10,  for  the  same  opinion;  and  for  arguments 
to  support  it. 

tSee  Plate  XXXV.  fig,  103,  6, 


244 


INSTRUMENTAL  LABOUR. 


keeping  it  in  close  proximity  to  the  head,  and  insinuating  it  with  the  same 
semi-rotatory,  wriggling  movement,  before  directed.  When  the  blade  is 
so  far  passed  up  that  the  point  approaches  near  to  the  sacral  promontory, 
the  handle  must  be  gently  drawn  backwards  towards  the  anus,  and  at  the 
same  time  somewhat  depressed ; the  point  will  then  slide  up  under  our 
fingers,  and  the  whole  blade  will  lie  flat  upon  the  foetal  skull.  Or,  to 
avoid  the  necessity  of  the  blade  making  a curcuit  of  any  part  of  the  pelvis, 
the  handle  may  be  depressed  below  the  bed-furniture,  and  the  point  at 
once  slipped  up  within  the  ilium,  between  our  fingers  and  the  head. 
This,  however,  requires  that  the  nates  of  the  patient  should  project  consi- 
derably over  the  bed’s  edge — a posture  difficult  to  obtain  and  to  preserve 
• — else  the  handle  cannot  be  sufficiently  lowered : and  since  the  cavity 
of  the  sacrum  is  not  occupied  by  the  head,  in  the  case  under  considera- 
tion, in  the  same  manner  as  it  is  when  the  short  forceps  are  applicable, 
there  is  not  the  same  difficulty  in  making  this  partially  circular  sweep, 
nor  the  same  chance  of  injury  attending  the  change  in  the  position  of  the 
instrument.  When  the  first  blade  is  properly  adapted,  it  must  be  retained 
in  its  situation  by  our  own  little  finger  and  thumb,  or  by  an  assistant,  and 
the  second  must  be  introduced  within  the  left  ilium, — guided  by  the  first 
two  fingers  of  our  left  hand, — exactly  in  the  same  manner  as  the  first, 
until  its  locking  part  slips  into  that  of  the  uppermost  blade.  If,  when  they 
are  both  fully  introduced,  it  is  observed  that  the  blades  are  not  perfect 
antagonists  to  each  other,  and  consequently  that  they  do  not  lock  easily, 
no  twisting  must  be  used  to  make  one  groove  fit  into  the  other, — no 
wrenching  or  screwing  round ; for  it  must  be  recollected  that  the  points 
are  actually  received  within  the  uterus,  and  that  the  neck  and  mouth  of 
the  womb  may  6e  seriously  injured  by  our  incautious  efforts ; — we  may, 
indeed,  do  infinitely  more  mischief  even,  than  if  we  employed  the  same 
force  while  adapting  the  short  forceps: — but  we  must  withdraw  the 
second  blade,  and  pass  it  up  again  in  a different  and  more  suitable  direc- 
tion. No  effort  at  extraction  must  be  made  until  the  lock  is  firmly  fixed. 
The  head,  then,  being  included  within  the  two  blades,  the  same  cautions 
must  be  attended  to  as  in  the  case  of  the  short  forceps.  A finger  must  be 
carried  quite  around  the  lock,  to  ascertain  that  none  of  the  mother’s  struc- 
tures are  trapped ; moderate  pressure  is  to  be  applied  by  our  hands ; and 
extraction  must  be  begun. 

We  are  sometimes  told,  that  we  must  never  think  of  having  recourse 
to  the  long  forceps  until  we  have  ascertained  with  certainty  to  which  side 
of  the  pelvis  the  child’s  face  inclines : but  this  information,  however 
desirable  it  may  be,  it  is  not  always  possible  to  gain,  even  in  cases  per- 
fectly adapted  to  the  instrument : for  the  head  is  usually  so  high  that  an 
ear  cannot  be  felt  without  passing  the  hand  into  the  pelvis,  and  carrying 


APPLICATION  OF  LONG  FORCEPS. 


245 


one  or  more  fingers  into  the  uterine  cavity — a measure  which  would 
produce  both  much  pain  and  some  danger:  while,  on  the  other  hand,  from 
the  puffy  state  of  the  scalp,  the  fontanelle  and  limbs  of  the  lambdoidal 
suture  can  scarcely  ever  be  distinguished ; so  that, — although  in  the 
earlier  part  of  the  process  we  might  have  been  able  accurately  to  satisfy 
ourselves  as  to  the  position  of  the  head, — when  called  to  a case  requiring 
the  assistance  of  the  long  forceps,  that  knowledge  is  obtained  with  great 
difficulty.  And  fortunately  it  is  not  absolutely  necessary,  for  the  success 
of  our  operation,  that  we  should  positively  learn  to  which  side  the  face  is 
directed  ; for  when  the  impediment  at  the  brim  is  overcome,  the  head 
will  generally  of  its  own  accord  turn,  with  the  face  towards  the  hollow 
of  the  sacrum,  without  the  use  of  any  directing  power  on  our  part : so 
that  we  ha  ve  only  to  follow  it  in  its  natural  inclination,  without  attempting 
to  guide  it.  In  Plate  XXXV.  fig.  104,  the  long  forceps  is  represented  as 
applied  when  the  principal  bulk  of  the  head  is  above  the  brim  of  the 
pelvis,  the  face  being  situated  towards  the  right  sacro-iliac  synchondrosis; 
one  blade  is  adapted  over  the  right  brow,  and  the  other  over  the  left  side 
of  the  occiput.  The  head  is  pictured  as  very  much  elongated,  consequent 
on  the  pressure  it  has  suffered. 

In  making  extraction,  the  same  pendulum-like  motion  must  be  used 
which  avails  us  with  the  shorter  instrument.  It  must  not  consist  of  a 
rapid  succession  of  short,  hasty  jerks,  nor  a strenuous  and  forcible  swing, 
but  of  a full,  slow,  regular  sweep  from  handle  to  handle,  the  lock  being 
kept  back  towards  the  perineum  as  closely  as  is  consistent  with  its  safety, 
while  slight  traction  is  exerted  downwards. 

As  soon  as  the  head  has  passed  the  contracted  brim,  and  has  become 
fully  lodged  in  the  pelvic  cavity,  we  usually  find  that  the  principal  diffi- 
culty has  vanished ; and  it  then  becomes  a question  in  what  way  the 
labour  should  be  terminated — whether  we  should  finish  it  with  the  instru- 
ments, as  first  applied, — whether  we  should  take  them  off,  and  leave 
the  case  to  be  completed  by  the  natural  powers, — or  whether,  on  their 
removal,  we  should  apply  a short  pair  over  the  ears,  and  act  according 
to  the  rules  previously  laid  down  : — and  I think  these  questions  can  be 
satisfactorily  answered;  for  each  mode  possesses  its  own  advantages, 
according  to  the  peculiar  features  of  every  case.  If,  then,  the  uterus  be 
acting  but  feebly,  either  from  exhaustion  or  any  other  cause,  while  at  the 
same  time  the  outlet  of  the  pelvis  is  of  the  ordinary  capacity,  and  the 
vagina  and  external  parts  are  soft,  flaccid,  and  distensible,  we  may  termi- 
nate the  labour  at  once  by  continuing  to  extract  with  these  instruments, 
without  changing  their  position,  because  there  is  little  risk  of  injury ; and 
if  the  remainder  of  the  case  were  left  to  nature,  much  time  might  unpro- 
fitably  glide  by,  before  its  completion.  If,  on  the  contrary,  the  pains  are 


246  INSTRUMENTAL  LABOUR. 

still  strong,  while  the  external  parts  continue  rigid,  the  outlet  of  the  pelvis 
being  well  formed,  it  would  be  better  to  remove  the  instruments,  and  to 
trust  the  conclusion  of  the  labour  to  nature’s  unaided  efforts.  But  should 
the  inferior  aperture  partake  of  the  distortion,  whether  rigidity  of  the  soft 
parts  exist  or  not,  we  might  then,  on  the  withdrawal  of  the  instrument, 
apply  the  short  forceps  over  the  ears,  and  cautiously  and  tenderly  termi- 
nate the  case  through  their  agency : and  I give  this  latter  recommendation 
because  of  the  probability  that  nature  will  not  herself  complete  the  delivery, 
and  because  the  short  forceps  are  much  less  likely  to  bruise  or  lacerate, 
being  applied  over  the  side  of  the  head,  than  the  long,  which  are  adapted 
to  the  occiput  and  brow. 

Cautions. — There  are  some  cautions  necessary  in  the  use  of  the  long 
forceps,  from  which  the  shorter  kind  are  exempt ; they  principally  are — 
First , that  we  should  not  apply  them  in  a case  where  great  distortion 
exists.  It  has  been  already  laid  down  as  a general  principle,  more  than 
once,  that,  unless  the  pelvis  possess,  in  its  conjugate  diameter,  three  inches 
of  clear  available  space,  we  cannot  expect  a full-grown  well-ossified  head 
to  pass  entire ; and  through  such  a diminished  aperture  we  are  not  to  hope 
that  we  shall  be  able  to  extract  it  by  the  forceps.  Burns,*  indeed,  fixes 
the  limit  of  the  deformity  which  would  indicate  the  use  of  the  long  for- 
ceps at  that  space.  Davis,*)-  from  the  observations  he  has  given  us,  would 
lead  us  to  believe  that  rather  more  was  generally  required  than  that  which 
Burns  specifies ; and  I am  inclined  to  think  that  unless  the  pelvis  measures  ’ 
at  least  three  inches  and  a quarter,  we  shall  generally  be  foiled  in  our 
attempts  at  delivery ; or,  at  least,  be  disappointed  in  our  hope  of  extracting 
the  child  living. 

Secondly— In  introducing  each  blade,  we  must  be  particularly  careful 
that  the  point  slides  within  the  os  uteri,  and  does  not  run  up  between  the; 
vagina  and  the  neck  of  the  womb,  lest  we  should  bruise  or  lacerate  that 
organ  at  its  junction  with  the  vagina;  and  especially,  lest,  in  attempting 
to  lock  the  blades,  we  should  pinch  its  structure  between  their  extremities ! 
and  the  child’s  head.  This  mischance  cannot  happen  with  the  short  for- 
ceps, because  the  os  uteri  must  be  entirely  dilated  before  their  application  ; 
and,  when  the  longer  pair  is  used,  may  be  avoided  by  taking  care  that  the 
point  is  constantly  kept  in  contact  with  the  foetal  cranium,  guided  by  two 
fingers  previously  inserted. 

Thirdly — That  we  should  not  employ  any  strenuous  endeavours  for 
effecting  delivery,  nor  work  with  them  for  too  long  a period  continuously. 
The  longer  the  instrument,  the  greater  leverage  we  possess  ; and  it  must 
be  evident  that  each  increase  of  leverage  augments  our  power : we  are 


Op.  Cit.,  p.  440. 


t Operat.  Mid.,  p.  230. 


CAUTIONS  IN  THE  USE  OF  LONG  FORCEPS.  247 

not  only,  therefore,  liable  to  use  too  much  exertion ; but  we  run  the  risk 
of  making  pressure  upon  structures  less  capable  of  sustaining  it  uninjured, 
than  when  we  employ  the  short  forceps.  Unless,  then,  a decided  advance 
be  evident  after  a few  minutes’  well-directed  efforts,  we  should  desist  from 
renewing  our  attempts;  and  we  must  judge  of  the  progress  we  are  making, 
by  examining  after  each  backward  and  forward  movement  of  the  instru- 
ment. We  must  most  scrupulously  avoid  using  forcible  means.  Force, 
indeed,  is  a word  which  should  be  expunged  from  the  vocabulary  of  obste- 
trical phrases. 

Fourthly — We  must  be  guarded  in  our  promises  regarding  terminating 
the  labour  by  the  means  we  are  about  to  resort  to ; because  it  is  impossi- 
ble that  we  can  measure  the  head  accurately  while  its  base  remains  above 
the  brim,  and  it  is  equally  impossible  that  we  should  be  able  to  form  an 
opinion  of  the  degree  of  ossification  it  has  acquired,  and  of  its  compressi- 
bility. In  all  these  points  we  may  be  deceived,  although  we  may  have 
made  ourselves  acquainted  with  the  capacity  of  the  pelvis  to  the  greatest 
nicety ; and  while  such  chances  of  deception  exist,  we  must  be  most  cau- 
tious not  to  add  disappointment  to  suffering.  I have  myself,  in  some 
instances,  been  foiled  in  attempting  to  extract  the  head  entire  through  a 
narrowed  aperture,  and  been  obliged,  eventually,  to  have  recourse  to  the 
perforator.  I always  feel  more  satisfied,  however,  in  lessening  the  head 
after  having  made  these  attempts,  because  I have  good  reason  to  think 
that  nature  unassisted  would  seldom  be  able  to  expel  a child  through  a 
pelvis  of  such  small  dimensions,  as  would  not  admit  its  passage  by  the  aid 
of  the  long  forceps ; — provided,  in  other  respects,  the  case  was  fitted  for 
the  employment  of  that  instrument.  I would  advise  the  operator,  then, 
before  proceeding  to  act,  not  to  make  a promise  of  delivery,  but  merely  to 
state  that  he  is  about  to  do  something  which  will  most  probably  relieve 
the  patient  materially,  and  that,  perhaps , he  may  at  once  terminate  the 
labour. 

After  all  I have  said  on  this  subject,  I must  not  close  my  remarks  with- 
out coinciding  in  opinion  with  Professor  Davis,  that  the  instrument, 
although  very  powerful  and  valuable,  is  at  the  same  time  very  dangerous 
in  its  use ; that  it  should  not  be  taken  in  hand  except  by  those  who  have 
acquired  some  proficiency  in  operative  midwifery ; and  that  it  is  to  be  had 
recourse  to,  more  as  an  experimental  measure  for  superseding  the  neces- 
sity of  destroying  the  child,  than  as  one  of  the  common  resources  of 
our  art. 


248 


INSTRUMENTAL  LABOUR, 


CRANIOTOMY. 

Of  all  instrumental  operations  in  obstetric  surgery,  the  perforation  of  the 
skull,  and  extraction  of  the  mutilated  foetus,  is  the  easiest  which  could  be 
undertaken,  for  delivery  in  any  case  of  impacted  head ; and  much  do  1 
fear,  that  to  the  facility  with  which  this  operation  can  be  accomplished 
have  been  sacrificed  the  lives  of  many  children.* 

It  may,  perhaps,  be  desirable  in  surgery,  whenever  necessity  compel 
us  to  perform  an  apparently  cruel  operation,  that  the  horror  which  th( 
simple  and  bare  mention  of  that  act  would  inspire  might  be  smothered  anc 
absorbed,  as  it  were,  by  the  sonorous  and  classical  title  which  it  bears 
but  by  whatever  name  it  is  called, — under  whatever  high-sounding  appel 
lation  it  is  disguised, — we  cannot  alter  or  conceal  the  fact  that  the  opera 
tion  consists  in  plunging  an  iron  instrument  into  the  centre  of  the  skull  o 
a human  being,  probably  at  that  moment  living,  and  extracting  it  aftei 
this  mutilation  has  been  practised. 

Some,  indeed,  horrified  at  this  arbitrary  destruction  of  foetal  existence 
have  laudably  contended  that  the  proceeding  is  not  justified  unless  th< 
child  be  dead : they  argue,  and  with  truth,  that  human  life  is  held  at  the 
will  of  one  Supreme  Being  alone, — and  that,  unless  forfeited  to  the  laws, 
to  no  human  hand  is  delegated  the  power  of  destroying  it.  Strong  ant 
valid  would  these  objections  be,  if  once  the  operation  were  performec 
wantonly,  or  without  grave  and  deep  consideration ; but  it  is  never  hac 
recourse  to,  except  for  the  purpose  of  saving  life,  or  preventing  future 
misery.  Did  the  mother  perish,  the  foetus  within  her  must  perish  like- 
wise; and  in  British  midwifery  we  consider  the  mother’s  life  as  paraj 
mount; — nay,  more,  we  think  ourselves  warranted  in  sacrificing  thf; 
infant,  if  that  be  the  only  way  to  preserve  her  person  from  those  dreadfu 
lesions  of  sloughing  and  laceration,  which,  if  they  took  place,  must — thougl! 
they  did  not  terminate  in  death — render  her  future  existence  a scene  o 
uninterrupted  wretchedness. 

Nor  are  there  wanting  arguments  sufficiently  strong  and  numerous  tc 
justify  our  practice.  These  are,  perhaps,  more  the  province  of  the  phi 
lanthropist  or  medical  jurist,  than  the  practical  surgeon:  but  I may  remark; 

* This  operation  has  been  described  under  various  terms — embryulcia  and  embryousia 
which  have  been  by  different  authorities  derived  from  i/x@puov  and  sxx®,  traho — or  exata,  abige 
— or  Qh*a),frango;  embryotomy,  from  t/u@pvov,  foetus  ; cephalotomy,  from  caput  ; and 

craniotomy,  from  Kpzviov,  calvaria , and  Tifxva,  scco.  The  latter  term  is,  I think,  in  most  com 
mon  use,  and  is  the  one  which  I shall  adopt. 


' 


* 


" * 


. 


v.  ...  • ' lypTf  • . 


UBRARV 
0,  THE 

university  of  iU-WOit 


V 


* f* 


CRANIOTOMY. 


251 


to  receive  the  teeth  of  the  others.)  This  is  formed  of  two  separate  blades, 
which  are  joined,  after  their  application,  by  a hinge  similar  to  that  of  the 
forceps;  one  of  these  passes  within  the  skull,  and,  being  furnished  with 
teeth,  perforates  the  bone ; while  the  other  is  introduced  externally  to  the 
cranium,  and  possesses  indentations  or  cavities,  into  which  the  teeth  of 
the  first  blade  are  received.  When  properly  fixed,  the  extremities  of  the 
handles  are  to  be  bound  firmly  together  by  a ligature,  and  steady  trac- 
tion applied : if  the  bones  are  very  strong,  and  the  diminution  of  space 
but  small,  this  instrument  is  most  powerful  and  highly  useful ; but  if  the 
bones  are  weak,  and  easily  give  way,  I cannot  help  considering  it  a 
more  dangerous  instrument  even  than  the  common  crotchet;  for,  while 
the  crotchet  is  fixed  within  the  skull,  the  finger  is  applied  exactly  opposite 
to  it  externally,  Plate  XXXVI.  fig.  1 1 1,  and  if  the  point  perforates  the  bone, 
or  slips  away  from  its  attachment,  it  cannot  injure  the  os  uteri  or  vagina, 
as  it  must  necessarily  come  against  our  finger.  But  when  the  craniotomy 
forceps  are  employed,  Plate  XXXVII.  fig.  113,#  it  is  not  possible  to  guard 
the  structures  from  laceration  in  the  same  manner:  their  teeth  are  cer- 
tainly well  sheathed  by  the  antagonist  blade ; but,  in  consequence  of  the 
perforations  which  they  make  in  the  bone,  its  structure  is  so  weakened 
that  it  easily  gives  way ; and  the  instrument  loses  its  hold,  and  breaks 
suddenly  out,  bringing  with  it  a portion  of  the  skull,  and  perhaps  some  of 
the  scalp  also.  This  accident  would  indeed  be  of  little  consequence, — no 
other  inconvenience  being  suffered  except  the  loss  of  the  purchase, — if  the 
angles  of  the  broken  bone  were  always  either  covered  by  the  scalp,  or 
sheathed  by  the  instrument  itself : but  this  I have  found  by  no  means  the 
case ; for  the  irregular,  jagged  edges  of  the  torn  bone  project  beyond  the 
margin  of  the  blades,  and — in  its  rapid  passage  through  the  vagina,  as 
the  instrument  breaks  from  its  hold — they  are  very  likely  to  tear  that 
organ,  as  well  as  the  external  parts.  For  these  reasons  I prefer  employ- 
ing the  latter  instrument,  although  I always  carry  with  me  the  craniotomy 
forceps  also.f 

Osteotomist. — This  instrument  is  intended  to  break  up  the  bones  of  the 
child’s  head,  particularly  at  the  base  of  the  skull,  so  as  to  enable  the 
operator  to  extract  the  foetus  through  a very  narrow  pelvis,  and  to  prevent 

* To  give  a full  view  of  the  pelvic  cavity,  the  right  hand  only  is  introduced  into  the  draw- 
ing,  embracing  the  handle  of  the  instrument;  in  practice,  however,  two  fingers  of  the  left 
hand  should  be  kept  in  contact  with  the  foetal  head,  during  extraction,  to  watch  the  descent 
and  afford  a degree  of  steadiness  to  the  operator. 

t Mr.  Holmes  has  improved  the  craniotomy  forceps  by  making  the  teeth  in  the  form  of  the 
teeth  of  a rabbit;  but  this  instrument  has  a fixed  joint,  and  it  appears  to  me  not  so  capable  of 
easy  application,  as  when  the  two  blades  are  introduced  separately,  and  united  by  a joint  such 
as  is  possessed  by  the  common  English  forceps. 


252 


INSTRUMENTAL  LABOUR. 


in  many  instances  the  necessity  of  having  recourse  to  the  Ccesarean 
section.  Fig.  109,  Plate  XXXVI.  represents  Davis’  osteotomis. 

It  cannot  be  necessary  to  give  a delineation  of  the  bone  forceps ; for  any 
common  pair  of  hinged  surgical  forceps,  provided  they  are  strong  enough, 
will  serve  the  purpose  of  removing  the  portions  of  bone,  broken  from  the 
skull  by  the  crotchet,  or  craniotomy  forceps. 

Cases  in  which  craniotomy  is  required. — I need  scarcely  repeat,  that 
although  on  some  occasions  we  may  feel  justified  in  having  recourse  to 
harmless  means  for  the  purpose  of  delivery,  before  exhaustion  has  pro- 
ceeded to  any  great  extent,  we  are  never  warranted  in  taking  the  per- 
forator in  hand,  unless  driven  to  it  by  a dreadful  necessity ; — provided, 
indeed,  there  is  any  doubt  as  to  the  child’s  being  still  alive  ; and  a well- 
grounded  hope  exists  of  its  being  expelled  by  the  natural  powers. 

Many  accidental  causes  may  occasionally  oblige  us  to  resort  to 
craniotomy — such  as  haemorrhage,  convulsions,  rupture  of  the  uterus, 
syncope,  and  other  anomalous  states  immediately  and  seriously  threat- 
ening the  mother’s  existence ; but  we  never  adopt  this  method,  if  a safe 
delivery  be  practicable  by  any  other.  It  is,  however,  by  far  most 
usually  found  necessary  where  disproportion  obtains  between  the  head 
and  the  pelvic  bones ; and  this  diminution  in  capacity  we  generally  observe 
at  the  brim,  in  the  conjugate  diameter, — as  has  been  more  than  onc^ 
remarked. 

I have,  indeed,  endeavoured  to  lay  down  a practical  rule  on  this  interest- 
ing subject,  founded  on  actual  measurement  of  the  pelvis  and  to  draw 
a distinctive  line  between  those  cases  in  which  it  is  possible  for  the  head 
of  a full-grown,  mature,  and  well-ossified  foetus,  tp  be  extracted  whole, 
and  those  others  where  a diminution  in  bulk  by  mutilation  must  be  prac- 
tised before  the  birth  can  take  place ; and  as  a principle,  we  regard  q 
pelvis  possessing  less  space  than  three  inches  in  the  conjugate  diameter? 
unequal  to  the  transmission  of  the  skull  entire.  Nevertheless,  it  behove^ 
us,  even  under  such  a diminished  capacity,  to  wait  as  long  as  is  at  at 
consistent  with  the  woman’s  safety,  before  we  employ  such  deadly 
means. 

It  is  by  no  means  necessary  for  the  success  of  the  operation,  that  the 
os  uteri  should  be  entirely  dilated;— the  wider,  indeed,  the  orifice  is 
opened,  the  less  chance  will  there  be  of  injuring  that  organ ; but  should  it 
not  have  acquired  a diameter  greater  than  that  of  half-a-crown,  we 
not  on  that  account  shrink  from  its  performance.  In  many  cases  I have 
been  compelled  to  deliver  by  these  instruments,  when  the  mouth  of  the 
womb  was  not  only  undilated,  but  still  possessed  of  considerable  rigidity. 


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CRANIOTOMY. 


253 


Mode  of  'performing  the  operation. — After  the  perfect  evacuation  of  the 
bladder  and  rectum, — the  patient  lying  in  the  usual  obstetric  position,  and 
two  or  three  folds  of  napkins  being  placed  under  her,  to  receive  the  por- 
tions of  the  cerebral  matter  as  they  escape, — two  fingers  of  the  left  hand 
must  be  carried  into  the  pelvis,  and  their  tips  brought  to  bear  against  the 
most  depending  part  of  the  skull.  The  perforator,  having  been  previously 
warmed  and  greased,  must  then  be  directed  along  the  groove  between  the 
fingers,  until  its  extremity  comes  in  contact  with  the  head ; a rapid  semi- 
rotatory or  boring  motion  must  be  given  to  the  instrument,  and  it  will 
soon  be  felt  to  perforate  the  bone,  and  enter  the  skull  itself;  it  must 
then  be  pressed  onwards  until  the  studs  prevent  its  passing  any  farther. — 
The  fingers  must  be  separated,  and  the  inner  edges  placed  against  the 
rests  of  the  instrument.  The  eye  at  the  extremity  of  the  lower  limb  must 
be  held  firmly  by  the  finger  and  thumb  of  our  right  hand,  while  an  assis- 
tant is  required  to  open  the  blades,  by  raising  the  upper  limb  to  the  extent 
of  three  inches.  Plate  XXXVI.  fig.  110.*  By  this  separation  of  the 
handles  a laceration  of  more  than  an  inch  in  length  will  be  made  in  the 
foetal  skull.  Provided  the  rests  be  well  protected,  there  is  little  likeli- 
hood of  any  injury  happening  to  the  maternal  structures  ; because  all  the 
cutting  portion  of  the  perforator  is  sheathed  within  the  head  itself.  The 
instrument  must  afterwards  be  half  turned  round,  without  being  with- 
drawn, and  the  edges  directed  respectively  towards  the  sacrum  and  pubes  ; 
the  handles  must  then  again  be  separated  in  exactly  the  same  manner,  so 
that  a crucial  aperture  may  be  formed  in  the  bones.  The  projecting 
stops  require  now  to  be  covered  by  the  fingers  with  even  greater  diligence 
than  before;  for,  independently  of  the  space  between  the  pubes  and  sacrum 
being  so  much  less  than  the  lateral  diameter,  there  is  greater  danger  of 
wounding  the  os  uteri,  the  rectum,  and  particularly  the  bladder,  while  this 
second  incision  is  being  made.  An  aperture  sufficiently  large  being 
obtained  to  admit  the  instrument  more  completely  within  the  cranium,  it 
must  be  introduced  beyond  the  rests,  and  turned  rapidly  round  in  every 
direction,  that  the  cerebral  mass  may  be  broken  dowrn  as  completely  and 
speedily  as  possible.  In  this  stage  of  the  operation  we  shall  find  the  scis- 
sors more  efficient  than  Denman’s  perforator ; because,  by  opening  and 
shutting  them,  we  can  more  perfectly  destroy  the  organization  of  the  brain, 
tear  the  vessels,  perforate  the  tentorium,  and  even  reduce  the  cerebellum 
into  fragments. 

* Holmes’  perforator  is  so  formed  that,  by  closing-  the  handles,  the  points  are  separated, 
and  the  object  of  the  invention  is  to  prevent  the  necessity  of  having  an  assistant ; one  hand 
only  being  required  to  make  the  aperture,  while  the  other  protects  the  rests.  In  remote  situa- 
tions of  the  country,  it  may  be  desirable  to  possess  this  instrument ; but  in  towns  and  popu- 
lous districts,  it  cannot  be  so  requisite,  because  assistance  is  always  at  hand ; and  the  amount 
of  help  we  want  may  be  afforded  even  by  a nurse. 


*254 


INSTRUMENTAL  LABUOR. 


It  is  of  much  moment  that  the  structures  at  the  base  of  the  brain  should 
be  broken  up,  if  possible ; for  organic  life  seems  mainly  dependent  on  their 
integrity;  and,  if  the  foetus  does  not  die  from  loss  of  blood,  the  nerves  may 
preserve  their  vitality,  and  perform  their  functions,  although  the  principal 
part  of  the  cerebrum  be  reduced  to  the  consistence  of  pulp,  or  even  eva- 
cuated. Instances  have  been  known  of  the  child  breathing  and  crying 
loudly  on  its  birth,  after  the  head  had  been  opened,  and  the  brain  partially 
extracted,* — than  which  no  accidental  mischance,  in  the  performance  of 
any  operation  whatever,  I should  imagine,  could  produce  a more  lively 
thrill  of  horror. 

A sufficiently  large  aperture  being  formed  in  the  bone,  the  second  part 
of  the  operation,  extraction,  must  be  commenced.  This  may  be  effected 
either  with  the  craniotomy  forceps  or  the  crotchet ; but,  for  reasons  pre- 
viously given,  I prefer  the  latter  instrument,— for  I have  found  that,  if  em- 
ployed with  due  caution,  it  is  less  dangerous  than  the  craniotomy  forceps, 
and,  if  a firm  hold  be  obtained,  almost  equally  powerful.  The  crotchet, 
then,  being  introduced  within  the  skull,  must  be  fixed  on  the  internal  sur- 
face of  the  bone,  wherever  there  is  sufficient  resistance  to  afford  the  neces- 
sary  purchase:  a finger  of  the  left  hand  must  be  kept  close  upon  the  head 
externally,  exactly  opposite  the  spot  on  which  the  extremity  of  the  instru- 
ment is  fixed  within : by  this  means  its  sharp  point  is  perfectly  covered, 
and  should  it  even  break  through  the  bone,  or  slip  from  its  hold,  the  fin- 
ger will  receive  it,  and  all  chance  of  tearing  the  maternal  structures  be  1 
thus  prevented.  Extraction  must  be  attempted  by  a steady  power  down- 
wards, applied  in  the  direction  of  the  axis  of  the  pelvic  brim,  which  is  in 
a line  from  the  umbilicus  to  the  coccyx. 

If  any  jerking  movement  be  resorted  to,  the  bone  will  certainly  be  broken, 
and  the  purchase  lost.  It  is  most  probable,  but  not  desirable,  that  after 
the  continuance  of  exertion  for  some  time  in  the  same  position,  the  point  j 
of  the  crotchet  will  perforate  the  bone,  and  be  felt  naked  by  our  finger  ; 
Plate  XXXVI.  fig.  Ill  ; it  will  then  be  of  little  avail  to  continue  o]urextrac- 
tive  efforts,  without  changing  the  situation  of  the  instrument,  because  that 
portion  on  which  it  has  been  fixed  will  soon  separate,  and  it  will  conse- 
quently tear  itself  away, — but  a fresh  purchase  must  at  once  be  sought  at 
some  other  part  of  the  skull,  and  the  same  steady  efforts  used  to  overcome 
the  difficulty. 

If  the  pelvis  be  considerably  contracted,  we  may  expect  that  much  ex- 
ertion will  be  necessary,  and  much  time  will  be  spent,  before  the  head 
passes  through  the  brim  ; and  we  must  not  be  disappointed  in  finding  the 
bones  break  constantly,  and  piece  after  piece  come  away.  The  loosened 


* Sec  Med.  Chirurg.  Review,  January  1834,  p.  204. 


CRANIOTOMY. 


255 


pieces  must  be  carefully  removed,  either  by  the  fingers  or  a pair  of  small 
forceps  contrived  for  the  purpose,  and  the  naked  edges,  still  remaining 
within  the  vagina,  studiously  covered  by  the  scalp.  In  this  manner  the 
parietal,  the  greatest  portion  of  the  frontal,  and  parts  of  the  occipital  bones, 
may  be  brought  away;  and  the  orbits,  or  the  foramen  magnum,  will  then 
afford  a strong,  and  most  valuable  hold  either  to  the  crotchet  or  blunt  hook. 
Should  the  blunt  hook  slip,  as  it  will  often  do,  or  the  crotchet  too  easily 
destroy  the  texture  of  the  bones,  recourse  may  be  had  to  the  craniotomy 
forceps,  the  greatest  care  being  taken  not  to  enclose  any  portion  of  the  os 
uteri  between  the  blades,  and  the  other  dangers  to  which  I have  before  ad- 
verted being  borne  in  mind. 

Another  great  objection  to  the  craniotomy  forceps  consists  in  the  diffi- 
culty of  their  re-adjustment  when  they  have  broken  from  their  previous 
hold  ; for  it  is  not  always  easy  to  find  a fresh  purchase  on  which  they  can 
be  applied  without  injury.  The  guarded  crotchet  of  Davis  will  sometimes, 
perhaps,  be  useful;  but  I cannot  help  thinking  the  best  security  the  patient 
can  experience  is  in  our  own  caution,  and  the  best  guard  we  can  employ, 
our  own  finger.*  Plate  XXXVII.  fig.  112,  represents  one  form  of  Profes- 
sor Davis’s  guarded  crotchet.  ( a represents  the  instrument  closed,  b the 
crotchet  blade  which  is  to  be  fixed  on  the  outer  part  of  the  skull.) 

It  is  recommended  by  some  practitioners,  that  we  should  endeavour  to 
break  up  the  cranial  bones  on  all  occasions  where  this  operation  has  be- 
come necessary,  and  take  them  away  separately,  as  soon  as  we  can  ac- 
complish it.  With  these  instructions  I cannot  coincide ; because  I have 
found  that  when  they  have  been  easily  separable  from  each  other,  in  con- 
sequence of  a high  degree  of  putrefaction  having  taken  place,  the  opera- 
tion was  both  more  difficult  and  more  dangerous  than  when  they  possessed 
a firmer  texture,  and  offered  more  resistance.  As  the  head  collapses  in  its 
passage  through  the  brim,  the  brain  oozes  out  of  the  opening  we  have 
made,  and  the  appearance  of  cerebral  matter  externally  is  almost  a sure 
sign  of  the  child’s  descent : it  will  be  received  on  the  napkins  previously 
applied,  which  should  be  removed  occasionally,  and  others  substituted,  at- 
tention being  paid  that  none  of  the  pulpified  mass  be  strewed  over  the  bed- 
furniture,  or  fall  upon  the  floor. 

There  can  be  no  necessity,  in  the  generality  of  cases,  for  the  introduc- 
tion of  a spoon  within  the  cranium,  or  any  other  kind  of  scoop,  for  the 
purpose  of  extracting  the  brain ; because  if  that  organ  be  broken  down, 
and  the  membranous  septa  within  the  skull  be  divided,  it  will  readily 
escape  when  our  extractive  effort  is  applied. 

It  happened  to  me,  on  two  occasions,  to  destroy  the  skull  so  entirely,  that  both  the  orbits 
and  the  foramen  magnum  had  given  way,  and  nothing  was  left  which  would  afford  a hold  to 
any  of  my  instruments.  In  these  cases  I delivered  eventually  by  turning,  not  without  sub- 
jecting the  patient  to  considerable  hazard. 


256 


INSTRUMENTAL  LABOUR. 


Some  have  advised  that,  after  perforation  was  effected,  many  hours 
should  be  allowed  to  elapse  before  extraction  was  attempted,  that  time 
might  be  given  for  the  bones  to  collapse ; and  that  the  diminished  head 
might  accommodate  itself  to  the  irregularities  of  the  pelvic  apertures.* 

From  this  recommendation,  also,  in  the  generality  of  cases,  I dissent, 
because,  if  we  have  delayed  operating  until  symptoms  threatening  exhaus- 
tion have  appeared,  we  cannot  expect  that  the  uterus  will  retain  sufficient 
power  to  accomplish  the  delivery,  or  even  to  propel  the  head  into  the 
pelvic  cavity : — besides,  in  so  acting,  we  are  lessening  the  chance  of  reco- 
very which  the  patient  enjoys,  by  adding  to  her  present  sufferings,  and 
allowing  her  system  to  become  hourly  more  depressed ; we  are  also  ren- 
dering the  operation  more  difficult,  by  losing  the  advantage  of  whatever 
eflergy  may  still  remain  to  the  uterus ; and  perhaps,  also,  by  permitting 
putrefaction  to  take  place ; under  which  state  the  bones  will  be  more  or 
less  loosened  from  their  attachment  to  each  other,  and  the  purchase  they 
ought  to  afford  necessarily  weakened.  If,  then,  we  subject  our  patient  to 
such  an  increase  of  danger,  and  render  the  operation  so  much  more  diffi- 
cult, especially  as  we  have  inflicted  the  summa  injuria  upon  the  infant, — 
what  advantage  can  we  gain  by  delaying  the  completion  of  the  delivery? 

Such  a proceeding  may  certainly  be  advisable  in  those  more  rare 
instances  of  extreme  deformity,  where  not  the  slightest  hope  exists  of  the 
head  being  expelled  whole,  and  in  which  early  perforation  is  had  recourse 
to,  under  the  conviction  of  its  absolute  necessity.  We  may  then,  while 
the  powers  are  strong  and  unimpaired,  wait  for  a few  hours  with  impunity; 
or  probably  even  with  benefit,  as  Osborn  suggested  ; but,  as  a general 
principle,  the  practice  is,  in  my  opinion,  to  be  deprecated. 

By  others,f  again,  we  are  recommended  to  seek  for  a suture  or  a fon- 
tanelle,  and  to  perforate  the  head  at  one  of  those  spaces,  because  the  instru-  * 
ment  more  readily  pierces  the  membrane  than  the  bone.  My  custom  is,  j 
to  make  the  opening  at  the  most  depending  part  of  the  head, — that  which 
is  most  readily  touched, — because  there  is  less  danger  of  injuring  the  os 
uteri — because  the  point  of  the  perforator  is  sufficiently  sharp  to  drill  a 
hole  through  the  bone  itself — and  because,  if  we  carry  it  to  one  side,  it  is 
very  likely  not  to  enter  the  head  at  all,  but  to  run  up  between  the  skull 
and  the  scalp,  merely  separating  the  one  from  the  other. 


* Osborn’s  Essays  on  Midwifery,  p.  233.  He  certainly  limits  this  delay  to  cases  where 
the  head  has  been  opened  early  in  the  labour ; but  he  recommends  that  extreme  measure  to 
be  resorted  to,  “ at  the  beginning  of  labour,  whenever  the  capacity  of  the  pelvis  is  only  two 
inches  and  three  quarters,  or  certainly  less  than  three  inches,”  in  the  conjugate  diameter, — a 
practice  which,  for  reasons  before  adduced,  I considered  most  unjustifiable, — provided  the 
space  between  the  pubes  and  the  sacrum  approaches  near  to  three  inches. 

t Baudelocque,  par.  1918,  Heath’s  translation,  recommends  that  a suture  should  be  opened 
if  possible. 


A'^./AA 


pj.xxxvh 


SIGNS  OF  THE  DEATH  OF  THE  FCETUS. 


257 


On  the  head  being  born,  it  must  be  enveloped  in  a napkin  ; and  it  is 
most  probable  that  a continuance  of  our  efforts  will  be  required  for  the 
extraction  of  the  shoulders.  If  much  difficulty  exist,  we  shall  be  assisted 
by  placing  another  napkin  round  the  neck;  and  traction  must  be  used  in 
the  direction  of  the  axis  of  the  brim,  viz.  in  a line  tending  towards  the 
coccyx.  It  may  often  even  be  necessary  to  introduce  a small  blunt  hook 
under  each  axilla  in  turn,  to  facilitate  the  exit  of  the  shoulders ; and 
sometimes,  also,  to  perforate  the  chest  or  abdomen,  before  delivery  can  be 
completed. 

Baudelocque*  counsels  that  after  extraction  we  should  inject  the  uterus 
with  warm  water,  to  wash  away  any  particles  of  brain  which  may  be 
lodging  in  that  cavity,  or  in  the  vagina  : this,  also,  I deem  useless;  because 
none  of  the  cerebral  substance  escapes  into  the  uterus,  and  what  lies  in 
the  vagina  must  be  perfectly  wiped  out  by  the  passage  of  the  foetal  body: 
as  forming  an  unnecessary  complication  of  the  operation,  therefore,  this 
advice  should  be  rejected. 

Signs  of  the  death  of  the  foetus. — It  is  highly  desirable, — as  well  for  the 
purpose  of  regulating  our  practice,  as  to  prevent  our  feelings  being  wounded 
without  cause,  in  case  the  child  should  have  already  lost  its  life, — that  we 
should  be  able  to  determine  whether  the  infant  be  dead  or  still  living. 
Many  symptoms  have  been  noted  as  indicative  of  the  loss  of  foetal  vitality 
— most  of  them  very  equivocal,  but  some  few  tolerably  certain. 

Those  signs  on  which  we  can  place  the  least  reliance  are — First , the 
loss  of  foetal  motion.  Secondly,  a sense  of  dull  weight  experienced  by  the 
mother  in  the  uterine  region.  Thirdly,  a sense  of  coldness  in  the  womb. 
Fourthly,  the  meconium  coming  away  under  a head  presentation.'  Fifthly, 
a putrescent  fcetor  in  the  discharges.  Sixthly,  discharge  of  flatus  from 
the  uterus.  Seventhly,  want  of  cerebral  pulsation. 

Those  which  are  much  more  satisfactory,  and  which,  indeed,  with 
some  limitations  presently  to  be  mentioned,  may  be  considered  conclusive, 
are — First,  loss  of  pulsation  in  the  funis.  Secondly,  desquamation  of  the 
cuticle.  Thirdly,  looseness  of  the  bones,  and  breaking  up  of  the  texture 
of  the  cranium.  Fourthly,  emphysema  of  the  scalp.  Fifthly,  stethoscopic 
observation. 

We  often  hear  it  advanced,  that  the  child  must  be  dead,  because  its 
movements  have  not  been  felt  for  a length  of  time ; and  the  mother  herself 
will  be  persuaded  that  such  is  the  case;  but  it  by  no  means  follows  that 
the  child  should  have  lost  its  life,  although  no  motion  may  have  been  expe- 
rienced for  a number  of  hours.  I have  already  mentioned  my  belief, f 
that,  under  the  compression  which  the  brain  suffers  in  labour,  the  foetus  is 

* Parag.  1,921,  Heath’s  translation. 


f Page  34. 


258 


INSTRUMENTAL  LABOUR. 


thrown  into  a state  of  partial  stupor ; during  the  continuance  of  which  it 
is  incapable  of  moving  its  limbs,  and  consequently  cannot  make  any  im- 
pression on  the  mother’s  sensibility.  The  brain,  indeed,  will  bear  with 
impunity  much  greater  pressure  before  birth  than  after  breathing  life  has 
commenced,  because  the  action  of  the  heart  is  less  dependent  on  the  ner- 
vous energy  being  sound  and  unimpaired,  than  is  the  function  of  the  respi- 
ratory organs  : compression,  then,  may  have  occurred  to  such  an  extent 
as  to  take  away  all  power  of  motion,  without,  so  far  interfering  with  the 
function  of  the  brain  as  to  suspend  the  heart’s  action.  M.  Merat,*  too, 
has  shown,  by  many  highly  interesting  experiments,  that  the  vitality  of 
the  heart  in  the  newly-born  animal  is  much  less  dependent  on  the  perfec- 
tion of  the  nervous  system,  than  after  breathing  life  has  been  continued 
for  some  time ; and  from  these  experiments  it  may  also  be  inferred  that 
the  heart  of  the  foetus  in  utero  is  more  independent  of  that  system  than  it 
is  after  birth.  Besides, — putting  out  of  our  consideration  the  probable 
effect  of  pressure  on  the  brain,— if  we  recollect  how  the  child’s  limbs  are 
cramped  after  the  membranes  are  ruptured,  we  shall  no  longer  wonder 
that  they  are  inactive.  Its  body  is  firmly  embraced  by  the  contracted 
fibres,  and  it  is  by  this  confinement  prevented  moving  in  any  direction. 

A dull  sensation  of  heaviness  in  the  uterus  has  been  enumerated  as  a 
second  sign.  It  is  alleged,  that  as  long  as  the  child  is  alive  there  is  a 
certain  degree  of  buoyancy  about  it,  which  is  lost  when  it  is  dead ; and 
that  a feeling  of  weight  is  consequently  experienced.  But  this  at  the  best 
is  very  questionable. 

A sense  of  coldness  in  the  uterus  is  given  as  another  sign.  It  is  sup- 
posed that  so  long  as  the  child  is  alive,  it  forms  heat  for  itself,  through  the 
medium  of  its  own  circulation ; but  when  it  is  dead,  it  abstracts  heat  from 
the  mother’s  body,  and  therefore  that  she  must  feel  a sefisation  of  cold. 
It  is  very  possible  that  this  position  may  be  correct,  but  it  does  not  follow 
that  the  inference  is  a true  deduction,  and — inasmuch  as  these  signs  are 
all  dependent  upon  the  mother’s  sensations,  and  consequently  upon  her; 
sensibility,  and  as  we  cannot  depend  upon  the  accuracy  with  which  she 
describes  her  feelings — we  could  not  rely  upon  their  infallibility,  even 
were  they  much  more  positive  than  they  really  are. 

The  coming  away  of  the  meconium,  when  the  head  presents,  is  assigned 
as  another  evidence  of  the  child’s  death.  It  is  assumed  that  the  bowels 
do  not  naturally  evacuate  themselves  into  the  uterus ; that  their  contents 
cannot  be  squeezed  out  by  the  action  of  the  uterine  fibres;  but  only  pass 
in  the  last  death-struggle  of  the  child,  or  after  the  sphincter  has  lost  its 
opposing  power.  That  this  does  not  always  hold  good  I have  myself  had 

* Diet,  dcs  Sciences  Medicates,  vol.  v.  p.  452. 


SIGNS  OF  THE  DEATH  OF  THE  F (E  T II  S,  259 


sufficient  proof:  besides,  a mistake  may  easily  be  made  on  this  subject. 
I have  already  mentioned,  that,  generally,  a brownish,  olive-coloured 
discharge  escapes  from  the  uterus  in  greater  or  less  quantity,  under 
•lingering  labour,  which  has  been  looked  upon  as  meconium  mixed  with 
the  liquor  amnii ; and  I have  known  such  an  appearance  adduced  more 
than  once  as  a proof  that  the  child  was  dead,  when  it  has  afterwards  been 
born  strong  and  healthy. 

The  discharge  possessing  a putrid  odour,  is  said  to  be  another  proof  of 
the  infant’s  death.  If  the  child  be  putrid,  unquestionably  the  discharges 
will  have  a foetid  smell;  but  it  does  not  follow  that  the  child  should  be 
putrid,  even  though  the  fluids  escaping  from  the  uterus  possess  an  unplea- 
sant foetor.  The  discharges  may  have  been  pent  up  within  the  womb, 
owing  to  the  head  being  impacted  in  the  pelvis ; and  a few  hours  will  be 
sufficient  to  induce  putrescency.  Nay,  the  liquor  amnii  has  been  some- 
times observed,  at  the  commencement  of  labour,  to  possess  a putrescent 
smell,  when  the  child  has  been  born  vigorous.  I grant  that  the  odour 
arising  from  the  mere  putrid  discharges  differs  considerably  from  that 
emanating  from  the  body  of  a foetus  dead  in  utero ; and  it  is  very  possible 
that  a person,  much  engaged  in  operative  midwifery,  might  be  able  to 
discriminate  between  them ; — of  the  two,  that  arising  from  the  death  of 
the  child  is  by  far  the  most  sickening : it  is,  indeed,  the  most  nauseous 
fume  that  can  possibly  assail  the  nostrils.  On  some  occasions  I have 
with  difficulty  restrained  myself  from  vomiting,  while  extracting  a putrid 
child  ; although  from  habit  I am  not  very  susceptible  of  such  impressions. 

A discharge  of  flatus  from  the  uterus  may  be  regarded  exactly  in  the 
same  light  as  the  appearance  of  putrid  fluid.  This  gas  is  generated  by 
putrescency,  and  will  often  escape,  on  the  opportunity  being  given  to  it, 
when  the  finger  is  carried  up  to  the  brim  of  the  pelvis  by  the  side  of  the 
child’s  head.  This,  therefore,  must  be  ranked  as  another  most  equivocal 
symptom. 

Nor  is  the  inability  to  discover  pulsation  through  a fontanelle  more 
conclusive.  Even  at  an  early  period  of  the  labour,  when  the  brow  pre- 
sents, it  is  very  seldom  indeed  that  we  are  able  to  distinguish  the  pulse  of 
the  cerebral  vessels : how  much  more  difficult,  then,  must  this  means  of 
diagnosis  become,  when  the  smaller,  posterior  fontanelle,  is  the  depending 
part ; and  especially  when  the  scalp  is  tumid  and  puffy,  owing  to  the 
collapse  which  the  bones  are  suffering. 

The  symptoms  more  to  be  depended  upon  are,  first,  the  funis  having 
prolapsed  before  the  head  of  the  child-«-having  remained  without  pulsa- 
tion for  a considerable  time,  and  having  become  cold  and  flaccid.  Here 
we  have  a positive  proof  that  death  has  taken  place.  But  does  it  neces- 
sarily follow  that  the  funis  belongs  to  that,  child  whose  head  is  at  the 


260 


INSTRUMENTAL  LABOUR. 


pelvic  brim  ? — Is  it  not  possible  that  there  may  be  twins  in  utero  ? — Is  it 
not  possible  that  both  the  bags  of  membranes  may  have  given  way,  and 
that  the  funis  of  the  second  or  uppermost  child  may  have  prolapsed  by  the 
head  of  the  first  ? — If  so,  might  not  the  first  child  be  alive,  though  the 
second  was  dead? — It  is  very  possible  that  such  should  be  the  case  ; but,  to 
produce  such  an  accident,  three  circumstances  must  concur — there  must 
exist  a plural  gestation ; the  liquor  amnii  of  both  children  must  be  eva- 
cuated ; and  the  funis  of  the  second  must  be  preternaturally  long,  to  have 
so  dropped  down.  It  is  a most  unusual  occurrence  for  the  membranes  of 
a second  child  to  burst  before  the  first  is  born ; and  the  prolapsus  of  the 
funis  belonging  to  that  child,  at  the  same  time,  would  be  such  a rare 
complication  of  chances  as  to  remove  the  case  entirely  out  of  all  calcula- 
tion : so  that  we  may  safely  regard  the  foetus  as  dead,  if  the  pulsation  in  the 
prolapsed  funis  have  entirely  ceased  for  the  period  of  thirty  or  forty 
minutes. 

Another  almost  unequivocal  sign  is  desquamation  of  the  cuticle.  If, 
under  a head  presentation,  we  can  bring  away,  between  our  fingers,  three 
or  four  hairs  having  some  of  the  cuticle  attached  to  their  roots,  we  may 
be  pretty  well  assured  that  the  child  is  dead.  But  even  this  is  not  an 
infallible  sign,  for  there  are  cases  on  record  to  prove  the  contrary.  A 
slough  may  have  occurred  in  the  scalp,  from  long-continued  pressure 
while  the  child  was  still  alive;  and  from  such  a spot  the  hair  and  cuticle 
might  be  removed  without  difficulty.  Hamilton*  used  to  mention  a case 
of  this  kind;  Baudelocquef  also  quotes  one;  and  Dr.  OrmeJ  met  with 
another,  where,  in  consequence  of  cutaneous  disease,  (probably  syphilitic,) 
the  cuticle  easily  desquamated.  Kennedy§  too  has  recorded  a similar  in- 
stance, in  which  there  existed  “ a livid  discolouration  of  the  whole  body, 
and  a complete  denudation  of  the  cuticle,  to  the  extent  of  several  square 
inches,  from  different  parts  of  the  surface  ; while  the  remainder  of  it  was 
so  easily  separable  as  to  be  removed  by  the  friction  of  the  clothing and 
yet  this  child  was  born  alive,  and  survived  its  birth  several  hours.  Such 
accidental  occurrences,  however,  are  most  unusual ; and  if,  at  the  same 
time  with  cuticular  desquamation,  the  discharges  were  very  foetid,  little 
doubt  could  remain  as  to  the  child  being  lifeless. 

A third  sign  is  the  breaking  up  of  the  structure  of  the  head  so  that 
when  we  touch  it  the  scalp  feels  loose,  as  if  it  enclosed  a number  of 
shells;  this  is  owing  to  the  brain  being  pulpified,  and  the  membranes  con- 
necting the  bones  having  become  softened,  and  having  partly  lost  their 


* MS.  Lectures,  1821.  t Translation,  vol.  iii.  p.  161,  note, 

t Blundell’s  Obstetricy,  by  Castle,  p.  552. 

§ On  Pregnancy  and  Auscultation,  p.  235. 


SIGNS  OF  THE  DEATH  OF  THE  FCETUS.  261 

uniting  power.  Together  with  this  breaking  up  of  the  structure  of  the 
head,  we  usually  also  observe  the  next  symptom — emphysema  of  the  scalp; 
which  produces  a crackling  sensation  under  the  fingers : and  if  these  indi- 
cations be  accompanied  by  the  peculiar  foetid  odour  I have  just  mentioned, 
we  may  be  sure  that  life  is  extinct.  These  three  occurrences,  indeed, 
can  only  take  place  when  the  child  has  been  dead  some  time,  and  putre- 
faction has  advanced  to  a considerable  height. 

The  last,  and  perhaps  the  most  satisfactory  means  of  ascertaining  the 
state  of  foetal  vitality,  is  stethoscopic  observation.  Laennec’s  instrument 
has  been  lately  used  with  the  view  of  determining  the  difficult  question  of 
doubtful  pregnancy;  and,  after  quickening,  the  sounds  of  the  heart  and  of 
the  placental  circulation  can  generally  be  easily  heard.  The  same  means 
has  also  been  resorted  to  for  the  purpose  of  ascertaining  whether  the  child 
be  alive  under  lingering  labour;*  and  promises  the  best  results,  to  those 
who  have  made  auscultation  a study.  The  beat  of  the  foetal  heart,  indeed, 
is  attended  with  such  a peculiar,  sharp,  and  rapid  tick , that  it  can  scarcely 
be  mistaken;  and  the  souffle  of  the  placental  circulation,  towards  the  close 
of  pregnancy  is  so  unlike  any  of  the  other  abdominal  sounds,  as  of  itself 
almost  to  form  a sufficiently  diagnostic  sign.  If,  then,  by  the  simple  ap- 
plication of  the  stethoscope  to  the  abdomen  of  the  parturient  woman,  we 
can  decide,  in  a doubtful  case,  on  the  present  state  of  foetal  vitality, 
we  shall  be  gaining  the  greatest  possible  advantage,  without  subjecting 
the  patient  to  the  least  pain,  danger,  or  inconvenience;  and  even  without 
shocking,  in  the  slightest  degree,  the  most  delicate  or  sensitive  mind:  since 
it  is  not  required  that  the  whole  of  her  dress  should  be  removed. 

I have  not  thought  it  necessary  to  dwell  upon  some  other  symptoms 
which  have  been  noticed  as  evidencing  the  child’s  death:  such  as  vomiting, 
shivering,  lividity  or  pallor  of  the  face,  discoloured  and  sunken  eye,  offen- 
sive breath,  or  extreme  languor  on  the  part  of  the  mother;  because  it  must 
be  evident  that  all  these  occurrences  may  take  place  from  many  causes 
entirely  referable  to  the  maternal  system,  and  perfectly  independent  of  any 
impressions  derived  from  the  state  of  the  foetus.  It  would  be  a waste  of 
words,  therefore,  to  canvass  their  separate  merits. 

Some  practitioners,  indeed,  think  it  altogether  useless  to  form  a diagno- 
sis on  the  state  of  foetal  vitality,  since  we  never  have  recourse  to  the  opera- 
tion of  craniotomy  except  where  delivery  has  become  requisite,  and  where 
the  perforator  affords  the  only  choice.  This  is  certainly  true  as  a princi- 
ple, but  exceptions  to  the  general  rule  will  constantly  occur.  On  many 
occasions  we  should  be  inclined  to  endeavour  to  deliver  by  the  forceps  or 
vectis,  if  we  had  any  suspicion  of  the  infant  being  still  alive,  although, 


Kennedy,  Op.  Citat.  p.  242. 


262 


INSTRUMENTAL  LABOUR. 


perhaps,  in  so  doing,  we  might  subject  the  woman’s  structures  to  some 
hazard ; while  on  others  we  should  be  perfectly  warranted  in  lessening  the 
head,  though  the  case  might  possibly  be  terminated  by  one  or  other  of 
those  instruments — provided,  indeed,  we  were  quite  certain  of  the  child’s 
death 

Although  it  is  often  difficult  to  distinguish  whether  the  foetus  be  still 
living,  before  the  operation  is  performed,  that  knowledge  is  easily  gained 
after  perforation  is  accomplished ; for,  if  the  heart  be  acting,  as  soon  as 
the  cerebral  vessels  are  ruptured,  a quantity  of  fluid  blood,  partly  arterial 
and  partly  venous,  will  escape  externally,  before  any  portions  of  brain  ap- 
pear; on  the  contrary,  if  the  circulation  have  quite  ceased,  no  flow  or  jet 
of  blood  will  take  place,  but  a number  of  small  clots  will  come  away  with 
the  cerebral  matter,  as  it  oozes  out  on  the  application  of  our  extractive 
efforts.  We  shall  observe  also,  on  the  birth  being  perfected, — if  the  foetus 
was  alive, — that  its  whole  person,  but  especially  the  face  and  lips,  present 
an  exsanguined  look,  in  consequence  of  the  cuticular  vessels,  as  well  as 
those  supplying  the  internal  parts,  being  drained  of  their  contents : and 
this  bloodless  appearance  has  led  me  to  suppose,  that  death  under  these 
circumstances  occurs  more  frequently  from  the  haemorrhage  which  it  has 
sustained,  than  from  the  injury  inflicted  on  the  brain  itself. 

These  remarks,  however,  are  of  no  importance,  practically,  in  regard 
to  the  case  under  treatment ; because,  whether  the  child  were  dead  or  not, 
the  act  cannot  be  recalled ; the  observation  is  only  valuable  for  our  own 
satisfaction — to  bring  peace  to  our  mind,  and  soothe  our  excited  feelings 
should  we  fortunately  ascertain  that  we  have  not  ourselves  been  the  instru- 
ments of  death,  but  that  it  had  occurred  from  the  hand  of  nature ; — and 
to  determine  the  correctness  or  fallacy  of  our  previously  formed  opinion, 
in  respect  to  the  child’s  state. 

Four  different  means  have  been  adopted  for  the  purpose  of  superseding 
the  necessity  of  resorting  to  craniotomy ; — they  are  the  Caesarean  opera- 
tion ; the  section  of  the  symphysis  pubis ; controlling  the  growth  of  the 
foetus  in  utero ; and  the  induction  of  premature  labour . 


THE  CAESAREAN  OPERATION. 


This  consists  in  dividing  the  abdominal  parietes,  cutting  into  the  cavity 
of  the  uterus,  and  extracting  the  child,  placenta,  and  foetal  membranes, 
through  the  incision  thus  made.* 


* Rousset  gave  the  term  Ca&arean  to  this  operation; — Hunc  nostrum  partum  Casarei  nomine 
inscripserimus. — (Bauhine’s  Trans,  chap.  1.)  And  he  adopted  it  from  Pliny’s  statement,  that 


THE  CESAREAN  OPERATION. 


263 


There  is  no  history  in  the  earlier  writers  on  medicine  or  surgery  of  any 
foetus  having  been  extracted  from  the  uterus  of  a woman  while  alive,  by 
this  operation ; and  the  date  of  its  introduction  cannot  be  traced  farther 
back  than  the  sixteenth  century. 

Rousset,  in  1581,  published  a work  in  Paris,  with  the  title  vG-TeporopoTOKix, 
in  which  he  strongly  advocated  the  operation,  and  gave  some  cases  of  its 
performance.  This  work  was  translated  from  the  French  into  Latin,  in 
1601,  by  the  celebrated  Caspar  Rauhine,  professor  of  medicine  at  Brazil ; 
and  it  was  chiefly  through  that  publication  that  the  Csesarean  section  be- 
came so  frequently  resorted  to  in  France,  and  other  parts  of  the  European 
continent  after  that  period.  The  first  successful  operation,  according  to 
Bauhine,  was  performed  at  Siegenhausen,  by  a cattle-gelder  named  Ales-, 
pachen,  on  his  own  wife,  about  the  year  1500.  She  afterwards  bore 
several  children  naturally.* 

I have  already  stated, f that  out  of  nearly  thirty  instances  in  which  the 
Csesarean  section  has  been  resorted  to  in  the  British  Isles,  in  three  only 
has  it  proved  successful,  as  far  as  the  preservation  of  the  mother  was 
concerned ; and  I have  endeavoured  to  account  for  the  great  disparity  in 
the  result  between  these  and  the  continental  cases.  I have  also  attempted 
to  lay  down  a rule,  limiting  the  instances  of  pelvic  distortion,  or  tumours, 
in  which  it  may  be  necessary ; requiring  it  at  the  same  time  to  be  borne 
in  mind  that  in  Britain  we  never  substitute  it  for  craniotomy  by  choice, 
but  only  have  recourse  to  it  when  no  other  mode  of  delivery  is  prac- 
ticable. 

Mode  of  performance.— The  patient  need  not  be  removed  from  the  bed ; 
but  lying  on  her  back,  with  her  head  and  shoulders  raised  by  pillows,  she 
should  be  brought  to  the  edge,  so  that  her  feet  may  hang  down  towards 
the  floor.  The  membranes  having  been  ruptured  per  vaginam , if  the 
liquor  amnii  is  not  already  evacuated,  the  bladder  perfectly  emptied,  and 
the  apartment  brought  to  a temperature  of  at  least  eighty  degrees  of 
Fahrenheit’s  thermometer,  an  incision  of  about  six  inches  in  length  must 
be  made  through  the  abdominal  parietes  below  the  navel,  parallel  with  the 
linea  alba,  a little  on  the  right  or  left  side  of  that  line ; to  be  determined 
by  the  conveniance  of  the  operator,  and  other  circumstances  of  the  case. 
Another  incision,  similar  to  the  first,  must  be  made  into  the  cavity  of  the 
uterus — the  hand  introduced,  the  membranes  torn,  and  the  child  extracted 

the  first  of  the  Roman  family  of  Caesars  had  that  surname  given  to  them,  because  he  was  ex- 
tracted from  the  womb  of  his  mother,  when  she  was  dying  or  just  dead.  “Auspicatius 
enectA  parente  gignuntur : sicut  ScipioA  fricanus  prior  natus,  primusque  Ccesarum , a caso 
matris  utero  dictus .” — (Nat.  Hist.  lib.  vii.  cap.  9 ; edit,  in  usum  Delph.) 

* Page  163,  Bauhine’s  Translation.  t Page  171. 


264 


INSTRUMENTAL  LABOUR. 


by  the  feet,  with  all  convenient  speed ; the  placenta  must  be  abstractec 
also  through  the  same  opening,  as  quickly  as  is  consistent  with  safety. — 
On  the  uterine  cavity  being  evacuated,  the  organ  will  contract  more  oi 
less  perfectly;  haemorrhage  will  thus  be  prevented,  as  well  from  the  divided 
vessels  as  those  over  which  the  placenta  had  been  attached;  and  there 
will  be  no  need  of  sutures  to  bring  the  edges  of  the  uterine  wound 
together.  The  abdominal  parietes,  however,  will  require  two,  or  perhaps 
three,  sutures : the  surfaces  must  be  dressed  according  to  the  common 
principles  of  surgery ; the  heat  of  the  apartment  gradually  lessened ; a 
tolerably  powerful  opiate  administered ; and  other  means  used  to  alia}/ 
irritability,  and  avert  inflammation  or  fever.  A warm  bath  should  be  in 
readiness,  and  the  proper  requisites  prepared  to  resuscitate  the  child,  ii 
animation  be  suspended. 

The  cautions  which  we  have  particularly  to  attend  to  in  the  perfor- 
mance of  this  operation,  axe,  first,  not  to  divide  the  tendinous  expansion 
of  the  recti  muscles  forming  the  linea  alba ; because  we  should  not 
expect  union  to  take  place  so  kindly  in  that  lowly  organized  structure,  as 
in  the  body  of  the  muscle  itself ; nor  to  make  the  incision  so  much  towards 
the  side  as  to  endanger  wounding  the  epigastric  artery.  Secondly , not  to 
allow  the  naked  surface  of  the  uterus  to  remain  exposed  for  a longer  time 
than  can  be  helped,  and  especially  not  to  handle  the  organ  more  than  is 
absolutely  necessary.  Thirdly,  not  to  make  the  incision  at  the  side  of 
the  uterus ; because  there  the  largest  uterine  vessels  take  their  course. — 
Fourthly,  not  to  let  much  time  elapse  between  the  extraction  of  the  child' 
and  placenta ; and,  fifthly,  to  be  most  careful  that  none  of  the  intestines 
become  strangulated,  by  passing  through  the  aperture  into  the  uterine 
cavity. — And  the  dangers  which  we  have  to  fear,  are,  the  excessive 
shock  which  such  a formidable  incision  must  produce  on  an  unhealthy,, 
debilitated,  and  perhaps  exhausted  frame;  haemorrhage  both  from  the! 
uterine  vessels  and  those  supplying  the  abdominal  parietes,  and  subsequent1; 
inflammation. 

It  is  very  possible  that  the  patient  may  sink  rapidly  after  the  operation,' 
from  the  sudden  shock  experienced  by  the  nervous  system ; but  this  has 
seldom -occurred.  Less  frequently  still  has  it  occurred  that  haemorrhage 
has  destroyed ; for  contrary  to  what  we  might  & priori  have  expected, 
the  bleeding  has  generally  been  comparatively  trifling.  Hull  tells  us  that 
in  both  his  cases  the  loss  of  blood  was  but  small.*  The  same  remark  applies 
to  two  of  Barlow’sf  cases,  although  in  one  the  placenta  was  attached 
directly  over  that  portion  of  the  uterus  through  which  the  incision  was 


* Letter  to  Simtnonds  in  defence  of  the  Cassarean  section,  p.  44. 
t Essays  in  Surgery  and  Midwifery,  cases  1 and  3, 


THE  CAESAREAN  OPERATION. 


265 


made ; also  to  a case  detailed  by  Mr.  Thomson,* * * §  and  to  most  others 
recorded.  Lauverjat,  a French  author,  towards  the  end  of  the  last  cen- 
tury, who  performed  the  operation  five  times, — three  of  which  cases  ter- 
minated favourably  for  the  mother, — recommends  even  that  the  loss  of 
blood  should  be  artificially  promoted,  by  separating  the  placenta,  and 
placing  a warmed  drinking  glass  over  the  denuded  surface ; “ that  such 
a quantity  of  blood  may  escape  as  is  jucfged  necessary  to  unload  the 
uterine  vessels  sufficiently.”!  He  confesses  that  this  advice  is  very 
different  from  that  previously  given  by  those  authors  who  had  written  on 
the  subject ; for  they  all,  fearing  excessive  hmmorrhage,  insist  on  the 
necessity  of  avoiding  the  placenta.  Lauverjat,  indeed,  may  possibly  have 
carried  his  principle  to  too  great  an  extent ; but  as  he  had  himself  operated 
in  five  cases,  his  opinion  proves  that  the  principal  objection  of  Pare,J  and 
others,  who  dreaded  the  excessive  haemorrhage  they  fancied  must  ensue, 
was  speculative  and  hypothetical. 

By  far  the  greatest  number  of  deaths  have  happened  from  inflammation 
supervening,  and  in  some  cases  terminating  in  gangrene : such,  then,  is  the 
evil  we  have  principally  to  dread.  It  was  suggested  by  the  ingenious  Dr. 
Aitkin§  of  Edinburgh,  that  the  injury  produced  on  the  peritoneum  was  the 
effect  not  so  much  of  the  violence  it  suffered  from  the  incision,  as  of  the 
introduction  of  atmospheric  air  into  the  abdominal  cavity,  and  the  irrita- 
tion consequent  on  its  admission;  and  he  proposed — to  obviate  this  chance 
of  danger — that  the  operation  should  be  performed  while  the  patient  was 
in  a warm  bath.  I do  not  know  that  his  suggestion  has  ever  been 
adopted ; and  I am  inclined  to  think  the  inconvenience  attending  such  a 
mode  of  proceeding  would  render  the  operation  much  more  difficult  and 
complicated.  Besides,  it  is  very  questionable  whether  his  position  be  cor- 
rect ; for  the  abdominal  cavity  in  dogs  and  other  animals  has  been  injected 
with  air  introduced  into  the  tunica  vaginalis,  and  passed  through  the  ring, 
without  any  other  inconvenience  being  sustained  beyond  what  the  bulk 
and  distention  produced;  and  it  has  been  found  that  in  time  the  elastic 
fluid  was  absorbed.  From  these  experiments,  as  well  as  from  observa- 
tions on  the  human  subject  in  the  case  of  accidental  wounds  of  the  abdo- 
men, there  is  good  reason  to  think  that  the  cause  of  danger  is  the  actual 
incision,  and  not  the  admission  of  atmospheric  air. 

Blundell||  suggests,  if  we  are  called  upon  to  perform  this  dreadful  ope- 
ration, that  we  should  endeavour  to  prevent  the  possibility  of  the  woman 

* Medical  Observations  and  Enquiries,  vol.  iv. 

t Nouvelle  Methode  de  pratiquer  l’Opcration  Cesarienne.  Paris  1788. 

X Johnson’s  Translation,  lib.  24,  cap.  31. 

§ Principles  of  Midwifery.  Third  edition,  p.  82. 

||  Obstetricy,  by  Castle,  p.  566. 

34 


266 


INSTRUMENTAL  LABOUR, 


qgain  conceiving.  He  therefore  proposes,  that  after  the  child  is  extracted, 
we  should  destroy  the  continuity  of  the  fallopian  tube  on  each  side,  by  re- 
moving a small  portion  of  its  substance.  By  this  means  we  should  not 
take  away  desire,  though  we  should  prevent  the  possibility  of  conception. 

Although  in  Britain  we  restrict  this  operation  on  the  living  subject  to 
such  extreme  disproportion  as  must  render  its  performance  very  infrequent 
indeed,  yet  the  case  is  widely  different  when  the  mother  has  expired,  and 
any  suspicion  is  entertained  of  the  child’s  survival.  Should  sudden  death 
occur  in  labour,  or  during  the  last  two  months  of  pregnancy,  it  would  be 
the  bounden  duty  of  the  attendant  surgeon,  after  having  stated  to  the 
friends  the  probability  of  saving  the  child’s  life,  to  proceed,  without  delay, 
to  extract  it  by  the  abdominal  incision ; and  if  such  means  were  used 
within  twenty  or  twenty-five  minutes  of  the  mother’s  decease,  the  result 
would  probabjy  be  favourable. 


SECTION  OF  THE  SYMPHYSIS  PUBIS. 


A second  means  proposed  for  the  purpose  of  superseding  the  necessity 
of  the  destruction  of  the  child,  is  the  division  of  the  symphysis  pubis, 
called,  after  the  name  of  the  proposer,  M.  Sigault — the  Sigaultean  opera- 
tion. 

It  has  been  at  different  times  generally  supposed  that  the  ligaments  of 
the  pelvis  gave  way  during  parturition : being  impressed  with  these  senti- 
ments, and  having  imbibed  the  opinions  of  the  older  anatomists,  “ ossa 
pubis  tuto  secari  possunt ,”  in  1768,  M.  Sigault,  then  a student,  proposed 
to  the  Royal  Academy  of  Paris  tp  enlarge  the  pelvis  under  contraction, 
by  cutting  the  symphysis  pubis.  The  suggestions  were  referred  to  a 
committee  of  that  learned  body ; and  these  gentlemen  having  taken  into  ‘ 
consideration  that  when  the  bones  were  separated  by  disease,  the  effects  ! 
of  that  separation  were  dreadful,  and  that  permanent  lameness  was  the 
result,  reported  that  the  operation  was  not  justifiable,  but  gave  the  pro- 
poser great  credit  for  his  ingenuity.  Although,  however,  Sigault  received 
such  a rebuff  at  the  outset,  he  was  not  to  be  deterred  from  his  purpose ; 
and  in  September,  1777;,  he,  assisted  by  M.  Alphonse  le  Roy,  performed 
the  operation  on  a patient  named  Souchot.  The  operation  is  described 
as  being  simple ; the  child  was  born  alive,  and  in  six  weeks  the  patient 
was  shown  to  the  medical  faculty  apparently  well.  But  notwithstanding 
that  the  supporters  of  symphyseotomy  boasted  of  the  case  as  one  of  per- 


THE  CjESARE  AN  OPERATION. 


267 


feet  recovery,  the  bladder  was  so  much  injured  that  she  was  never  able 
to  retain  her  urine  so  long  as  she  lived.* 

Denmanf  states,  that  when  the  accounts  of  the  supposed  success  of  this 
. operation  were  brought  to  England,  he  had  a conference  with  John  Hun- 
ter on  the  subject;  and  it  was  determined,  as  far  as  the  safety  of  the 
woman  was  concerned,  that  if  the  good  contemplated  could  result,  the 
section  of  the  symphysis  itself  would  not  warrant  opposition  to  it ; but  with 
regard  to  its  utility,  it  was  necessary  that  experiments  should  be  made  to 
establish  that  point.  These  experiments  were  afterwards  made  by  Dr. 
William  Hunter,  and  it  was  proved,  that,  by  a simple  division  of  the  pubes, 
although  the  bones  spontaneously  separated  somewhat,  very  little  space 
was  gained ; but  for  that  object  it  required  that  they  should  be  wrenched 
asunder,  to  the  imminent  danger  of  the  sacro-iliac  ligaments  and  joint, 
and  especially  also  to  the  bladder  and  its  attachments.  In  cases  of  dis- 
tortion, I have  already  proved  that  the  diminution  of  space  is  principally 
in  the  conjugate  diameter ; and  it  was  found  that,  in  order  to  increase  this 
diameter  one  inch,  the  pubes  must  be  separated  three  inches ; and  to  in- 
crease it  half  an  inch,  there  must  be  a separation  to  the  extent  of  two 
inches.  It  was  proved,  also,  that  if  a separation  of  an  inch  and  a half 
only  took  place,  laceration  of  the  sacro-iliac  ligaments  occurred ; and  it 
may  well  be  presumed  that  this  must  be  attended  with  fatal  consequences.! 

It  must  be  evident  from  this  statement,  that  the  operation  is  not  justifi- 
able in  cases  of  the  more  deplorable  distortion  of  the  pelvis,  and  therefore, 
in  England  at  least,  it  cannot  supersede  the  Caesarean  section : nor  is  it 

* Among  some  manuscript  papers  of  the  late  Dr.  Dennison,  which  came  into  my  posses- 
sion,  I find  a note  that  he  had  seen  this  patient  while  in  Paris,  and  should  have  considered 
her  quite  well,  “ had  not  his  nose  informed  him  that  she  could  not  retain  her  urine.”  The 
praise  bestowed  on  M.  Sigault  in  Paris,  and  throughout  France,  was  quite  unprecedented;  a 
medal  was  struck,  by  order  of  the  faculty  of  Paris,  bearing  the  motto,  “ Sectio  Symph.  oss.  pub. 
lucina  nova , anno:  1768  invenit,  proposuit,  1777  fecit  feliciter  J.  R.  Sigault , D.  P.  M.  Juvit 
Alph.  le  Roy , D.  M.  P.,”  to  commemorate  the  event;  a royal  pension  was  granted  to  him,  and 
the  applause  he  received  Was  perfectly  extravagant : greater  exaltation  he  could  scarcely  have 
enjoyed,  if  he  had  devised  a method  to  remove  female  nature  beyond  the  pale  of  all  the  pains 
and  dangers  connected  with  parturition. — Baudelocqu'e,  vol.  iii.  p.  240,  translation.  In  no 
other  country,  perhaps,  but  among  our  enthusiastic  and  volatile  neighbours,  would  an  opera- 
tion of  such  a kind,  resting  on  one  solitary  trial  alone,  have  given  rise  to  so  universal  a 
triumph.  Soon  it  was  repeated,  with  various  success,  on  the  continent;  of  forty-four  women 
who  were  subjected  to  this  operation  in  different  countries,  fourteen  died,  and  many  of  those 
who  survived  were  grievously  injured  for  life ; and  of  the  children  not  more  than  fifteen  were 
saved. — (Merriman’s  Synopsis,  p.  168.)  It  has  only  been  performed  once  in  Great  Britain  ; 
Mr.  Welchman  was  the  operator;  and  an  account  of  the  case  will  be  found  in  the  London 
Medical  Journal  for  1790,  p.  46. 

1 System  of  Midwifery,  chap,  xii;  sect,  xi; 

t See,  in  confirmation,  the  details  of  some  interesting  experiments  by  Baudelocque,  parag. 
{2006  et  seq.r  translation ; and  Velpeau,  edit.  Bruxel.  p.  446. 


268 


INSTRUMENTAL  LABOUR. 


justifiable  in  the  smaller  degrees  of  diminution,  because  in  them  craniotomy 
can  be  performed ; and  it  has  been  laid  down  as  a maxim,  that  the  life 
even  of  the  foetus  must  be  sacrificed,  if  that  be  necessary  to  preserve  the 
woman’s  structures  from  such  dangerous  injuries  as  the  section  of  the 
symphysis  must  occasion.  The  division  of  these  bones,  then,  can  neither^ 
become  a substitute  for  the  Caesarean  operation,  nor  for  craniotomy ; it  is 
now  never  thought  of  in  England,  as  a means  of  delivery,  and  is  also,  I 
believe,  totally  exploded  from  continental  practice.* 

CONTROLLING  THE  GROWTH  OF  THE 
FCETUS  IN  UTERO. 


In  the  lesser  degrees  of  deformity,  (putting  those  aside  which  would 
require  our  having  recourse  to  the  Caesarean  section,  and  which  fortu- 
nately occur  so  rarely  as  to  place  them  almost  beyond  the  bounds  of 
calculation,)  it  becomes  a great  object  that  we  should  be  saved  the  neces- 
sity, for  the  preservation  of  the  woman’s  life,  of  destroying  each  child 
that  she  conceives ; and  with  this  view  the  third  expedient  has  been 
attempted, — controlling  the  growth  of  the  foetus. 

It  was  with  justice  supposed  that  if  the  growth  of  the  child  in  utero 
could  be  regulated  so  as  to  prevent  its  rapid  increase,  it  would  pass 
through  a contracted  space  so  much  the  more  readily,  and  that  this  might 
be  accomplished  through  the  medium  of  the  mother’s  system.  The  idea 
was  suggested  by  the  late  Mr.  Lucasf  of  Leeds,  who  adduces  some 
instances  in  which  a spare  diet  appeared  to  be  usefully  enjoined.  Analogi- 

i*.  **\ 

* An  operation  somewhat  similar,  but  much  more  horrible  in  character,  was  proposed  by 
Dr.  Galbiati  of  Naples  in  1832,  and  performed  by  him  in  this  year.  The  patient  was  only 
“ three  feet  and  a half  and  some  inches”  high,  and  the  pelvis  measured  “ about  an  inch 
between  the  promontory  of  the  sacrum  and  the  pubes,  between  the  same  and  the  right  ilium 
about  an  inch  and  a half,  or  a little  more;  and  between  the  same  and  the  left  ilium  only  a 
few  lines.  “ The  operation  was  commenced  at  7 p.  m.,  March  30th.  The  rami  of  the  pubis 
and  ischium  of  the  right  side  were  sawn  through,  as  near  the  acetabulum  as  possible,  and  the 
symphysis  pubis  divided;  as  the  space  thus  gained,  however,  was  found  to  be  insufficient  for 
the  head’s  descent,  and  11  p.  m.,  April  1st,  the  bones  on  the  left  side  were  cut  in  the  same 
manner  as  had  been  done  on  the  right,  and  the  head  was  brought  down  into  the  pelvis  by  the 
forceps.  The  child  was  now  discovered  to  be  dead,  and  the  case  was  therefore  terminated 
by  destroying  the  texture  of  the  head.  The  woman  died  on  the  3rd,  at  5 a.  m.  The  opera- 
tion  was  sanctioned  by  other  practitioners. — La  Pelviotornia  ragguaglia  di  una  nuova  opera- 
zione  di  chirurgia  che  puo  con  vantagio  sostituirsi  alia  Caesarea,)— Gen.  Galbiati  Napoli, 
1832. 

t Mem.  Medical  Society,  London,  vol.  ii.  p.  412. 


INDUCTION  OF  PREMAT  UR  E LABOUR.  269 


cal  reasoning  was  brought  to  bear  on  the  question  ; and  it  was  argued 
that  if  cows  were  kept  in  a luxuriant  pasture,  their  calves  were  much 
larger  and  stronger  than  if  their  food  was  less  plentifully  supplied.  Absti- 
nence was  therefore  recommended  in  the  human  subject.  This  possibly 
may  be  the  case  with  cows;  but  even  if  it  be,  the  principle  unfortunately, 
does  not  hold  good  with  regard  to  our  own  species : both  the  observation 
of  disease,  and  direct  experiment,  prove  the  contrary.  We  observe  that 
women  labouring  under  the  last  stage  of  the  most  debilitating  diseases, 
such  as  phthisis,  often  bring  forth  plump  and  well  nourished  children.  We 
remark,  also,  frequently,  that  the  vomiting  which  usually  attends  the  first 
weeks  of  pregnancy  continues  almost  uninterruptedly  during  the  entire 
period,  so  that  scarcely  the  whole  of  any  meal  is  retained  upon  the  sto- 
mach ; and  that  the  patient  becomes  much  emaciated  under  the  debili- 
tating effects  consequent : yet  the  nutrition  of  the  foetus  is  not  interfered 
with  ; but  it  is  born  strong,  hearty,  and  of  full  size.*  But  the  question  has 
been  settled  by  experiments  made  directly  for  the  purpose ; and  it  has 
been  shown  beyond  a doubt,  that  whatever  influence  the  regimen  adopted 
by  a pregnant  woman  may  have  on  the  development  of  her  foetus,  the 
system  of  diet  cannot  be  reckoned  among  the  resources  of  our  art,  to  be 
depended  upon  in  the  least  degree. 


INDUCTION  OF  PREMATURE  LABOUR. 


Nature  herself  first  pointed  out  the  most  likely  means  to  remedy  the 
evils  which  disease  had  entailed.  It  could  not  but  be  observed  that  when 
women  with  small  pelves  went  into  labour  prematurely,  their  infants 
passed  with  little  difficulty.  Thus  practitioners-)*  were  led  to  reason  on 
the  subject  and  to  endeavour  to  induce  uterine  action  before  the  termina- 
tion of  gestation,  in  consideration  of  the  amazing  growth  that  the  foetus 
undergoes  during  the  last  two  months,  and  the  probability  that  a child 
born  after  the  completion  of  the  seventh,  would  be  reared.  DenmanJ 
records,  that  in  1756  a solemn  consultation  between  the  obstetrical  prac- 
titioners in  London  took  place  on  the  subject,  in  which  the  morality, 
safety,  and  utility  of  the  means,  were  fully  discussed. 

As  to  the  morality , there  can  be  but  one  opinion.  If  the  life  of  the 


* Baudelocque,  parag.  1992,  Heath’s  translation. — For  the  Effect  of  Diet  on  Pregnant 
Females,  see  Merriman’s  Synopsis  p.  299. 

t Dr.  Macauley  was  the  first  physician  in  London  who  induced  premature  labour  with 
success,  in  the  year  1756. 
t System  of  Midwifery,  chap.  xii.  sect.  x. 


270 


INSTRUMENTAL  LABOUR. 


child  can  probably  be  saved,  and  if  much  danger  can  be  averted  from  th<i 
mother,  the  morality,  as  a surgical  means  of  procuring  a great  benefit 
must  be  self-evident.  Should  premature  labour  or  abortion  be  induced 
to  screen  an  individual  from  the  just  reproaches  of  the  world,  or  to  cas 
into  oblivion  the  evidence  of  the  gratification  of  a Criminal  passion,  then 
indeed,  is  murder  committed  in  law  and  reason : but  as  our  object,  under 
the  Circumstances  now  treated  of,  is  to  save  life,  arid  as  probably  twc 
beings  may  at  the  same  time  be  preserved  to  society  by  the  means  pro- 
posed, the  profession  now  entertains  no  question  as  to  its  morality,  when 
imperious  necessity  dictates  it. 

With  regard  to  the  safety  also,  all  must  be  agreed  ; for  how  much  more 
likely  is  the  woman  to  survive,  having  passed  a foetus,  after  a compara- 
tively short  labour,  which  may  weigh  five  pounds,  or  five  pounds  and  a 
half,  and  but  little  ossified,  than  if  she  produce  one  at  the  full  time,  weigh- 
ing seven  pounds  or  more,  whose  osseous  system  is  well  developed, 
after  a difficult  and  protracted  struggle,  terminated  too  by  instrumental 
delivery  ! 

The  utility , indeed,  as  far  as  regards  the  preservation  of  the  child’s  life, 
becomes  a separate  question ; and  Baudelocque*  has  reasoned  speculatively 
against  it.  The  strongest  argument  he  uses  is,  that  when  the  liquor 
amnii  is  discharged  after  the  rupture  of  the  membranes,  there  must  be, 
such  pressure  on  the  funis  umbilicalis  and  the  body  of  the  child  as  to 
destroy  its  life;  especially  as  the  os  uteri  will  most  likely  dilate  with  diffi- 
culty. It  certainly  is  true  that  more  children  are  born  dead,  after  the 
induction  of  premature  labour,  than  if  they  come  into  the  world  at  the 
full  time ; but  provided  we  can  snatch  only  a proportion  from  death,  still 
our  object  is  in  a very  great  measure  gained.-)* 

w-  i 

* Parag.  1983  et  seq.,  translation. 

t Professor  Hamilton  states,  (Practical  Observations,  1840,  p.  285,)'  that  of  forty-six  infants 
thus  prematurely  brought  into  the  world  by  his  agency,  forty-two  were  born  alive ; and  that  in 
one  patient  he  performed  the  operation  upon  different  occasions.  Much  greater  success  has  at- 
tended Hamilton’s  endeavours  than  I can  boast  of.  In  my  practice  more  than  one-half  have  been 
born  alive,  and  might  live  to  maturity.  It  occurred  to  me,  between  the  years  1823  and  1834, 
to  be  compelled  to  induce  labour  prematurely  forty  times.  This  may  geem,  perhaps,  a very 
large  number ; and  in  explanation  I may  state  that  the  extensive  charity  which  has  supplied 
the  principal  part  of  these  cases,  embraces  the  districts  of  Spitalfields  and  Bethnal  Green, 
which  parishes,  I have  reason  to  believe,  contain  more  females  with  deformed  pelves, 
congregated  together,  than  are  to  be  met  with  over  the  same  quantity  of  square  acres  in  any 
other  part  of  this  kingdom.  When,  also,  it  is  taken  into  consideration,  that  in  most  of  the 
patients  the  operation  has  been  repeated,  and  that  some  have  undergone  it  five  and  six  times, 
the  subjects  of  it  will  be  found  to  be  comparatively  few.  Gut  of  these  forty,  one  was  a twin 
case;  and  of  the  forty-one  children,  twenty-three  were  born  alive.  But  suppose  even  that  the 
child  should  be  born  dead,  still  we  are  giving  to  the  mother  the  best,  and  to  it  the  only, 
chance  of  life;  and  we  save  the  mother,  at  the  same  time,  a great  deal  of  personal  suffering. 


INDUCTION  OF  PREMATURE  LABOUR.  271 


Difficulties  in  effecting  the  object. — The  difficulties  which  we  have  to 
contend  with  in  endeavouring  to  save  the  child  under  the  proposed  plan, 
are  certainly  great;  and  the  following  maybe  enumerated.  First,  the 
pressure  on  the  navel-string  may  destroy  its  existence,  as  advanced  by 
Baudelocque.  There  can  be  no  doubt  that  as  long  as  the  membranes  are 
whole,  however  strongly  the  uterus  may  act,  the  pressure  on  the  fcetal 
body  and  funis  is  inconsiderable,  owing  to  the  quantity  of  inelastic  fluid 
which  the  womb  contains.  But  as  soon  as  the  water  is  evacuated,  when 
the  parietes  of  the  uterus  come  into  close  contact  with  the  body  of  the 
child,  it  is  very  possible  that  the  funis  umbilicalis  may  suffer  such  injurious 
compression  as  to  destroy  the  child’s  life ; and  this  will  therefore  be  looked 
upon  as  one  of  the  chances  militating  against  success. 

Secondly , it  is  observed  that  children  more  frequently  present  in  a pre- 
ternatural position,  when  expelled  before  the  end  of  gestation,  than  after 
the  full  time  is  completed.  At  a particular  period  of  pregnancy  the  foetus 
assumes  a definite  posture,  from  which  it  seldom  after  varies.  What  this 
precise  period  is,  I have  no  direct  means  of  judging ; probably  it  differs 
much  in  different  cases ; but  the  fact  is  undoubted,  that  cross  births  are 
more  frequently  met  with  under  premature  labour,  either  spontaneous  or 
artificial,  than  in  full-timed  pregnancies.  Of  thirty-four  children  born 
after  the  induction  of  premature  labour — which  cases  came  under  the 
knowledge  of  Dr.  Merriman* — fifteen  presented  preternaturally,  and  only 
one  of  these  was  saved.f  The  same  observation  I have  myself  made, 
though  the  proportion  has  not  been  so  large ; for,  of  the  forty-one  children 
just  alluded  to,  fourteen  presented  preternaturally;  and  DuboisJ  has  stated, 
that  jn  the  Maternite  at  Paris,  during  the  year  1829,  and  the  three  follow- 
ing, out  of  one  hundred  and  twenty-two  children  born  before  the  comple- 
tion of  seven  months,  in  fifty-one  cases  the  pelvis  offered  itself,  and  in  five 
the  shoulder ; making  a total  of  nearly  one-half  preternatural  presenta- 
tions. Thus,  then,  if  the  shoulder  or  breech  present,  we  shall  have  little 
Chance  of  saving  the  child ; because,— besides  the  ordinary  cause  of  dan- 
ger,— the  pressure  on  the  funis  umbilicalis  must  be  great  when  the  head 

I have  not  been  able  to  put  the  result  of  my  practice  on  this  interesting  subject,  since 
1834,  into  a tabular  form;  but  as  far  as  memory  will  serve,  I have  reason  to  believe  that  the 
proportion  of  children  saved  during  the  last  six  years,  has  been  rather  larger  than  the  fore- 
going  average. 

* Synopsis,  p.  172. 

t Hamilton  looks  upon  this  large  proportion  of  preternatural  presentations  as  very  extraor- 
dinary, (Op.  Cit.,  p.  283;)  and  states  (p.  289)  that  out  of  fifty-nine  cases  “ under  his  care,  and 
that  of  the  medical  attendants  of  the  Edinburgh  Lying-in  Hospital,  there  were  only  five  such.” 
Dubois’  returns,  Merriman’s  observations, and  my  own  practice,  would  tend  to  prove  it  was  not 
so  remarkable  as  the  professor  imagined. 

t Mem.  de  l’Academie  Roy  ale  de  Medecine,  tom.  ii.  p.  271. 


272 


INSTRUMENTAL  LABOUR. 


is  passing  the  brim  T for  I presume  on  there  being  a want  of  space  to  war- 
rant a recourse  to  the  means  used.  Barlow,*  indeed,  states  that  he  is 
induced  to  believe  preternatural  presentations  are  more  frequently  met 
with  under  distortion  of  the  pelvis  than  when  that  organ  is  well  formed. 
This  remark  coincides  with  my  own  observations ; but  how  a contraction 
of  the  pelvic  brim  can  influence  the  position  of  the  foetus  in  utero,  it  is 
difficult  to  explain,  or  even  to  imagine. 

The  third  difficulty  we  have  to  contend  with,  is  the  chance  of  decep- 
tion regarding  the  period  of  pregnancy  at  which  the  operation  is  performed. 
Women  are  very  liable  to  be  deceived  in  their  reckoning;  they  may  fancy 
they  are  advanced  farther  than  is  really  the  case,  and  their  representations 
may  induce  us  to  bring  on  uterine  action  before  the  foetus  has  acquiredj 
such  a degree  of  perfection  as  to  enable  it  to  sustain  independent  exist- 
ence:—or,  on  the  other  hand,  the  patient  may  have  been  pregnant  before 
she  was  aware  of  it ; and  we  may  delay  the  operation  until  it  is  too  late 
— until  the  child  is  of  too  great  a bulk,  and  too  strongly  ossified,  to  pass 
through  the  particular  pelvis  which  the  woman  possesses ; and  we  may 
consequently,  in  the  end,  be  compelled  to  resort  to  the  operation  of  crani- 
otomy ; as  has  occurred  to  myself  in  more  than  one  instance.  Though 
these  difficulties,  then,  are  some  drawback  to  our  success  in  anticipating 
the  proper  period  of  labour,  yet  they  are  by  no  means  such  as  would 
induce  us  to  discard  the  benefits  it  holds  out. 

Means  adopted , — Various  modes,  both  by  internal  medicines  and  man- 
ual operation,  have  been  proposed  for  the  purpose  of  bringing  on  prema- 
ture labour.  Of  these,  the  only  positive  sure  method  consists  in  the  de- 
struction of  the  integrity  of  the  ovum  ; for  when  this  is  effected,  the  pro- 
cess of  gestation  is  interrupted,  and  that  of  labour  soon  commences.  The 
operation  requires  that  we  should  possess  a most  accurate  knowledge  of 
the  anatomy  both  of  the  ovum  and  the  maternal  structures,  and  be  well; 
acquainted  with  the  state  of  development  which  the  cervix  uteri  assumes  at 
different  periods  of  pregnancy ; else  the  most  serious  evils  may  result,  as  is 
testified,  indeed,  by  the  criminal  records  of  many  civilized  nations. 

Some  years  ago  I had  an  instrument  made,  of  very  simple  construction, 
on  the  principle  of  the  tonsil-lancet,  but  shaped  like  a female  catheter, 
which  I have  been  in  the  habit  of  employing  with  the  intent  of  putting  a 
stop  to  the  process  of  gestation  in  those  unfortunate  cases,  where  the  for- 
mation of  the  woman  precludes  the  hope  that  she  will  be  able  to  bear  a child 
at  the  perfection  of  its  intra-uterine  maturity.f 


* Essays  on  Surgery  and  Midwifery,  p.  348. 

t The  following  sentence  briefly  describes  the  mode  of  using  it : — Duobus  sinistrre  mantis 
digitis,  primo  secundoque  videlicet,  in  vaginam  intromissis,  index  per  os  uteri  inserendus  est ; 
deinde  instrumentum,  illo  digito  directum,  usque  ad  ovuli  membranas  adferendum  ; quo  facto 


INDUCTION  OF  PREMATURE  LABOUR. 


273 


Unless  a quantity  of  water  is  present  between  the  two  layers  of  the 
fetal  membranes,  the  prescribed  method  will  invariably  induce  uterine 
action  earlier  or  later ; but  should  the  amnion  still  remain  entire,  gestation 
may,  and  probably  will,  proceed  uninterrupted.  The  time  which  elapses 
between  the  operation  and  the  commencement  of  parturient  pains,  varies 
exceedingly.  I have  known  the  uterus  begin  to  act  in  ten  hours,  and  I 
have  also  known  nearly  a week  pass.  We  usually  observe  that  in  fifty 
or  sixty  hours  uterine  contraction  is  fully  established. 

If  it  is  proposed  to  induce  labour  prematurely  by  opening  at  once  into 
the  amnial  cyst,  the  kind  of  instrument  I have  just  adverted  to  will  answer 
the  purpose  as  well  as  any  other,  and,  in  the  hands  of  a practitioner  ac- 
quainted with  the  anatomy  of  the  structures,  will  perfectly  protect  the 
mouth  and  neck  of  the  uterus  from  any  chance  of  injury.  But  by  allow- 
ing the  liquor  amnii  to  drain  away  before  the  os  uteri  is  dilated — which 
must  necessarily  happen  when  the  ovular  membranes  are  punctured — the 
foetal  body  will  be  subjected  to  such  pressure  as  greatly  to  endanger  its 
existence.  This  consideration  has  led  some  practitioners*  to  adopt  a dif- 
ferent method.f 

Could  we  always  rely  on  success  following  the  proceeding  mentioned 
in  the  last  note,  it  would,  no  doubt,  be  much  preferable,  both  on  the  mo- 
ther’s and  child’s  account,  to  the  one  more  commonly  practised ; but  I 
have  found  it  fail  in  most  of  the  instances  where  I have  adopted  it.  Never- 
theless, being  impressed  with  the  great  advantage  of  preserving  the  mem- 
branes whole,  I made  some  experiments  with  a medicine, J now  well 
known,  and  found  expulsive  action  soon  follow  its  exhibition  in  all  the 
instances,  with  very  few  exceptions,  where  I administered  it. 

After  a great  number  of  trials,  however,  I observed  that,  although  the 
mothers  recovered  as  well  as  if  they  had  gone  through  an  ordinary  labour, 

ejus  punctum  occultum  dextrce  mantis  pollice  inttis  pressum  tenuia  fcelCis  involucra  facild 
aperit,  aqua  uterina  per  canalem  argenteum  liber6  fluit,  parttisque  dolores  mox  superve- 
nient. 

* Hamilton,  Op.  Cit.,  p.  284.  See  also  Davis’s  Operat.  Mid.,  p.  280. 

t Ab  uteri  ore  membranas,  digito  immisso,  ad  pollicis  circiter  spatium  undique  separant; 
mucum  viscosum  ex  cervice  demovent;  et  irritationem  adeo  excitatam  satis  esse  ad  partum 
preematurum  inducendum  existimant. 

$ The  following  is  the  form  I have  been  accustomed  to  use : — 

g<  Secalis  Cornuti  recentis,  in  pulverem  redacti,  spij.;  aquae  ferventis  §viij.  Infunde 
vase  levit£r  clauso  per  semihoram,  et 

£ Liquoris  Colati,  gviiss.;  Acidi  Sulphurici  Dil.jgss;  Syrupi,3'ij.;  Spiritus  Cinnamoni, 
3ij.  M.  sumantur  cochl.  duo  4UL  qu&que  hor&. 

Parths  dolores  decern  vel  duodecim  elapsis  horis  eegram  vexare,  et  post  singulas  medicin® 
potiones  clard  augeri,  srepe  inveni;  aliquando  etiam  oriri  primo  potato  haustu. 

35 


r 


274  INSTRUMENTAL  LABOUR. 

their  systems  not  being  in  any  sensible  degree  injuriously  affected  by  the 
drug,  (and  in  some  instances  between  thirty  and  forty  doses  were  taken,) 
yet  that  the  proportion  of  children  born  still  was  greater  than  when  the 
membranes  were  punctured.  This  I attributed  to  the  baneful  influence  of 
the  medicine  upon  the  foetus : I was  consequently  led  to  modify  the  prac- 
tice ; and  I am  now  in  the  habit  of  administering  four  or  five  doses,  at 
intervals  of  four  or  six  hours,  and  of  rupturing  the  membranes  after  their 
exhibition.  I have  generally  remarked  that  the  os  uteri  has  become  soft, 
and  mostly  somewhat  opened  under  the  action  of  the  drug ; and  the  in- 
crease of  live  births  has  been  larger  when  this  system  was  followed,  than 
after  any  other  which  I have  tried. 

When  necessary. — Unless  deformity  of  the  person  generally,  and  of  the 
pelvis  in  particular,  exist  to  an  extreme  degree,  the  induction  of  premature  j 
labour  in  a first  pregnancy  is  not  to  be  thought  of ; for  it  is  impossible  to  j 
become  acquainted  with  the  exact  size  of  the  different  diameters  of  the 
pelvis,  except  during  labour;  and  in  the  cases  ordinarily  met  with,  no  one 
would  be  justified  in  having  recourse  to  so  serious  a measure,  if  he  had 
not  accurately  ascertained  the  dimensions  by  personal  examination — and 
that  under  the  most  favourable  circumstances  for  obtaining  the  required 
information.* 


* The  liability  incurred  by  every  man  in  undertaking-  to  bring  on  labour  prematurely  is 
so  great  that  it  makes  it  most  desirable — nay  even  absolutely  necessary — for  the  sake  of  his 
own  character,  that  he  should  not  perform  any  operation  with  that  view,  until  a consultation  i 
is  held  upon  the  case,  and  the  means  proposed  is  sanctioned  by  some  other  practitioner.  I 
would  particularly  warn  my  younger  brethren  against  acting  on  the  representations  of  the 
patient  herself  alone;  and  of  the  following  two  cases,  one  will  point  out  the  necessity  of  such 
a caution.  In  the  year  1825,  I was  applied  to  by  a woman,  of  whom  I had  no  previous  know- 
ledge, to  induce  labour  prematurely.  She  stated  that  she  had  lived  at  the  west  end  of  London, 
but  had  come  to  reside  not  far  from  my  house;  that  two  of  her  children  had  been  destroyed,' 
and  that  twice  also  premature  labour  had  been  induced  by  a highly  respectable  practitioner  < 
in  the  neighbourhood  where  she  then  resided.  I wrote  to  this  gentleman  on  the  subject,  who1: 
gave  me  such  satisfactory  reasons  for  what  he  had  done,  that  I had  no  hesitation  in  acceding 
to  her  request.  Since  that  time  I have  brought  on  labour  prematurely  for  that  woman  on  ; 
five  different  occasions. 

In  the  year  1831,  my  father  was  applied  to  by  a patient,  also  to  induce  labour.  She  stated 
that  her  child  had  been  destroyed  in  the  birth  by  a physician  practising  at  the  western  part 
of  the  metropolis — a gentleman  who  holds  a high  rank  in  the  profession ; and  that  she  never 
could  bear  a living  child  at  full  time.  My  father  took  the  precaution  to  see  this  gentleman, 
that  he  might  learn  from  him  the  particulars  of  the  case,  and  was  informed  that  the  woman 
was  believed  to  be  unmarried,  that  she  had  placed  herself  under  the  care  of  a midwife,  and 
that  he  had  been  applied  to  in  consequence  of  a violent  attack  of  convulsions  which  occurred 
during  the  labour;  on  which  account  alone  he  had  thought  it  requisite  to  perforate  the  head. 
My  father  then  refused  to  comply  with  her  wishes;  but  she,  still  desirous  of  placing  herself 
under  his  care,  took  apartments  in  the  neighbourhood,  and  gestation  was  allowed  to  proceed 
to  its  termination.  My  father  attended  her.  Some  delay  occurred  in  the  labour,  which  in- 
duced him  to  request  my  assistance,  and  I delivered  her  of  a living  child  by  means  of  the 


INDUCTION  OF  PREMATURE  LABOUR. 


275 


It  becomes  a question  of  very  great  nicety,  what  degree  of  contraction 
would  warrant  us  in  proposing  this  measure.  As  it  has  been  frequently 
laid  down  as  a principle  that  a child  at  full  time  may  pass  through  a pelvis 
containing  in  its  conjugate  diameter  at  the  brim  three  inches,  we  may 
hope,  if  the  aperture  exceed  that  dimension,  that  the  foetus  may  be  born 
living,  naturally,  provided  the  outlet  be  well  formed : and  with  this 
space  we  should  not  be  inclined  to  adopt  any  means  by  which  gestation 
might  be  suspended,  unless,  indeed,  some  extraordinary  circumstances 
called  for  our  interference;  such  as  the  patient  invariably  bearing  very 
large  children,  or  other  accidental  causes  equally  uncontrollable. 

If,  then,  the  conjugate  diameter  measure  a little  less  than  three  inches, 
we  may  allow  pregnancy  to  advance  to  the  end  of  eight  months ; if  about 
two  inches  and  three  quarters,  to  seven  months  and  a half ; if  about  two 
inches  and  a half,  it  must  not  proceed  beyond  seven  months ; if  the  space 
be  less  than  two  inches  and  a half,  it  would  be  certainly  unsafe  to  delay 
our  means  beyond  seven  months;  and  I would  be  inclined  to  induce  labour 
rather  sooner;  because  children  of  an  earlier  period  have  been  reared.* 

It  is  a prejudice  as  old  as  Hippocrates’  time,  that  a child  of  seven  months 
is  more  likely  to  live  than  one  of  eight  months’  intra-uterine  age;  and  it 
is  still  in  force  among  the  common  people,  not  only  in  this  country,  but 
on  the  continent.  Such  an  opinion,  however,  is  contrary  to  experience, 
as  well  as  to  analogy  and  all  philosophical  reasoning ; for  we  should  cer- 
tainly expect  that  the  longer  the  foetus  remained  in  utero,  the  more  com- 
pletely would  the  respiratory  and  digestive  apparatus  be  perfected ; and 
the  greater  capability  would  it  have  acquired  to  sustain  an  independent 
existence.  This  supposition,  in  fact,  we  find  practically  verified ; and  we 
should,  therefore,  delay  our  attempts  until  the  last  day  which  we  think 
consistent  with  its  passage  through  the  pelvis  entire  and  uninjured.  Plate 
XXXVII.  fig.  114,  the  principal  features  of  which  are  copied  from  Smel- 
lie,  shows  a premature  head  passing  through  a contracted  pelvis,  and  well 
displays  the  compressibility  of  the  skull. 

Other  circumstances  may,  however,  call  for  our  interference  in  the 
manner  proposed,  besides  diminution  of  the  pelvic  capacity : thus,  if  it 
should  have  occurred  to  the  same  woman,  in  a number  of  successive  preg- 


forceps.  We  found  a slight  contraction  at  the  outlet  of  the  pelvis,  which  was  the  occasion  of 
the  difficulty  experienced.  I have  great  doubts  that  her  object  in  desiring  to  have  premature 
labour  induced,  was  the  preservation  of  her  infant. 

* In  one  case  I thought  it  right  to  bring  on  labour  at  six  months  and  a half,  scarcely  anti- 
cipating, however,  to  save  the  child ; because,  having  delivered  the  patient  previously  by 
craniotomy,  I had  a full  knowledge  of  the  very  small  size  of  the  pelvis  she  possessed.  Even 
at  this  early  period,  X found  the  child  had  acquired  too  great  a bulk  to  pass  entire,  and  I was 
obliged  to  open  the  head.  I was  afterwards  told  th’ut  this  poor  creature  went  to  Malta  with 
her  husband,  and  there  died  in  labour. 


276  CONSEQUENCES  OF  LINGERING  LABOUR. 


nancies,  to  be  aware  of  the  death  of  her  infant  at  a particular  period  to- 
wards the  close  of  gestation, — about  the  termination  of  the  eighth  month, 
for  instance, — and  if  the  death  was  to  be  attributed  to  deficiency  of  nourish- 
ment, or  any  other  cause  decidedly  referable  to  the  maternal  system,  it 
would  become  a matter  for  consideration  whether  a chance  of  life  might 
not  be  afforded  to  her  future  infants  by  the  induction  of  labour  before  the 
usual  period  of  their  death.  Under  such  a state,  however,  it  would  be 
necessary  to  weigh  most  minutely  every  circumstance  connected  with  the 
case,  and  all  the  peculiarities  attendant  on  it.* 

Other  states  of  disease,  in  which  the  mother’s  life  is  placed  in  immi- 
nent jeopardy, — provided  there  is  good  reason  to  suppose  her  danger  is 
aggravated  by  the  continuance  of  pregnancy, — may  warrant  us  in  having 
recourse  to  the  induction  of  premature  labour:  thus,  Hamiltonj*  used  to 
say  he  had  twice  resorted  to  the  expedient,  with  the  view  of  preserving 
the  mother ; in  one  of  which  cases  dropsy  induced  him,  and  the  other, 
deadly  exhaustion  and  depressed  vital  powers.  For  such  anomalous 
cases,  however,  it  must  be  evident  that  no  general  rule  can  by  possibility 
be  laid  down. 

It  would  be  right,  in  every  instance  where  premature  action  is  induced, 
that  a wet-nurse  should  be  engaged  to  take  charge  of  the  child  immedi- 
ately on  its  birth. 


CONSEQUENCES  OF  LINGERING  LABOUR. 


Exhaustion.'— After  lingering  labours,  whether  instruments  have  been 
used  or  not,  the  generality  of  women  recover  tolerably  well ; but  occa- 
sionally very  bad  symptoms  manifest  themselves,  the  consequence  of  de- 
pression from  loss  of  power,  'excitement,  or  injurious  pressure. 

Sometimes  the  system  falls  into  a state  of  exhaustion,  from  which  it 
never  rallies.  The  symptoms  indicating  such  a condition  would  gene- 


* On  one  occasion  I was  consulted  by  a pregnant  woman  for  a small  tumour  at  the  upper 
part  of  the  thigh,  which  was  evidently  of  a malignant  nature;  it  increased  so  rapidly,  that  it 
was  clear,  if  she  were  allowed  to  attain  her  full  period,  it  would  in  all  probability  have  ac- 
quired such  a magnitude  as  to  preclude  the  possibility  of  extirpation.  I requested  the  opinion 
of  my  father  and  Mr.  Luke,  who  coincided  with  me  as  to  the  character  of  the  disease, — as  to 
the  hazard  of  performing  the  operation  under  pregnancy, — and  as  to  the  danger  of  allowing 
the  full  term  of  gestation  to  arrive.  I therefore  brought  on  premature  labour  about  the  end 
of  seven  months : she  was  received  into  the  London  Hospital  as  soon  after  as  was  safe ; the 
tumour  was  removed,  and  she  enjoyed  her  former  health.  The  child  presented  with  the 
breech;  the  labour  was  somewhat  lingering;  and  it  was  unfortunately  born  dead, 
t MS.  Lectures,  1821. 


CONSEQUENCES  OF  LINGERING  LABOUR.  277 

rally  be  observed  before  instruments  were  had  recourse  to  : under  it  the 
mental  and  bodily  powers  are  completely  worn  out ; the  pulse  flags ; the 
extremities  become  cold;  there  are  weariness  of  the  limbs,  vomiting, 
sunken  features,  and  a hollow  eye  ; probably  no  pain  is  complained  of,  and 
the  expression  of  the  face  is  sufficient  to  indicate  the  danger.  Stimulants, 
nourishment,  cordial  medicines,  opium,  and  aether,  are  the  best  and  only 
means  to  restore  the  ebbing  vitality. 

Inflammation  of  the  pelvic  viscera. — After  lingering  labour,  the  viscera, 
at  the  lower  part  of  the  abdomen  and  pelvis,  often  go  into  a state  of  inflam- 
mation : suppuration  may  occur,  but  it  is  not  usual ; the  inflammation  gene- 
rally terminates  in  resolution  or  sloughing.  This  state  is  known  by 
shivering,  general  fever,  and  local  pain, — by  a quick  pulse,  white  tongue, 
thirst,  heat  and  dryness  of  skin,  deficient  secretion  of  milk,  and  by  the 
lochia  being  suppressed,  or  scanty  and  of  bad  odour ; and  there  is  pain  on 
pressing  the  lower  part  of  the  belly.  If  the  uterus  feels  large,  hard,  and 
painful,  most  likely  the  inflammation  is  principally  confined  to  that  viscus ; 
but  if  the  pain  is  more  general,  and  the  swelling  less  circumscribed,  the 
probability  is  that  the  disease  is  more  diffused,  and  there  is  a greater  chance 
of  its  terminating  in  sloughing  of  the  vagina. 

Suppuration  is  known  to  have  supervened  by  occasional  rigours  occur- 
ring,— by  the  sharpness  of  the  pain  experienced, — by  the  pulse  increasing 
in  rapidity  and  falling  in  power, — and  by  hectic  fever.  The  tongue  be- 
comes furred ; and  there  is  purging  and  sweating,  and  vomiting,  and  wast- 
ing of  the  body : generally  the  bad  symptoms  increase,  and  the  patient 
dies  ; but  sometimes  the  abscess  will  burst  into  the  vagina,  and  give  almost 
immediate  relief. 

Deep  collapse. — A state  of  deep  collapse  may  be  produced  by  the  ex- 
tensive contusions  and  subsequent  mortification.  The  entire  prostration 
of  strength,  the  muttering  delirium  and  watchfulness,  the  cold  clammy 
extremities,  the  quick,  weak,  tremulous,  and  often  irregular  pulse,  will 
sufficiently  characterize  this  state;  while  the  purgings  and  vomitings,  and 
aphthous  mouth,  will  indicate  the  extent  of  danger. 

Sometimes,  the  parts,  rather  by  their  own  healing  powers  than  by  the 
aid  of  medicine,  will  become  restored ; the  symptoms  will  gradually  abate ; 
the  different  organs  will  slowly  regain  their  healthy  functions  ; and  after 
hovering  on  the  brink  of  destruction  for  some  weeks,  by  a strong  effort  of 
the  constitution,  the  patient  will  unexpectedly  rally.  At  other  times  the 
parts  will  slough,  and  various  will  be  the  extent  of  the  destruction  pro- 
duced. Occasionally,  the  bladder,  rectum,  and  all  the  coats  of  the  vagina, 
will  become  gangrenous ; the  three  cavities  will  be  thrown  into  one ; and 
if  the  patient  survive,  of  which  there  will  then  be  little  chance,  most  mise- 
rable indeed  must  be  the  remainder  of  her  life.  At  others,  merely  a por- 


278  CONSEQUENCES  OF  LINGERING  LABOUR. 


tion  of  the  mucous  membrane  of  the  vagina  will  slough.  Constitutional 
irritation,  varying  in  degree,  will  supervene,  which  will  cease  on  the  heal- 
ing process  being  established ; a cicatrix  will  be  formed,  and  this  will 
most  likely  impede  the  passage  of  the  child  during  a subsequent  labour ; or 
it  may  even  narrow  the  canal  to  such  an  extent,  as  to  prevent  marital 
intercourse. 

Treatment. — Little  can  be  done  by  medicine  under  this  unfortunate 
condition.  The  parts  may  be  fomented,  and  the  strength  must  be  sus- 
tained. The  introduction  of  a piece  of  lint,  soaked  in  turpentine  and  oil, 
has  been  recommended  to  facilitate  the  slough’s  separation.  As  soon  as 
the  patient  is  able  to  be  moved,  she  should  be  sent  into  the  country : a 
change  from  the  close  atmosphere  of  town  to  a more  healthy  air  has  often 
given  a fillip  to  the  constitution,  has  renovated  the  sinking  powers,  and  put 
an  immediate  check  to  some  of  the  worst  symptoms,  especially  continued 
purging. 

Inability  to  pass  urine  after  delivery  is  not  an  infrequent  consequence 
of  lingering  labour.  It  arises  from  turgescence  of  the  vessels  of  the  ure- 
thra and  neck  of  the  bladder,  or  perhaps  from  spasm  of  the  sphincter. 

The  introduction  of  a catheter  two  or  three  times  in  the  twenty-four 
hours  is  necessary  in  every  case  where  the  bladder  does  not  void  its  con- 
tents. Occasionally,  after  an  instrument  has  been  used  for  the  purpose, 
the  patient,  for  two  or  three  days,  passes  her  water  tolerably  well ; and 
subsequently  it  comes  away  involuntarily.  Under  this  state,  if  the  labour 
has  been  tedious,  it  is  always  to  be  suspected  that  a slough  has  taken  place 
at  the  neck  of  the  bladder,  or  in  the  track  of  the  urethra,  especially  if  at 
the  same  time  there  be  a foetid  discharge,  and  most  particularly  if  a small 
piece  of  membranous  substance  has  been  voided ; this,  on  being  washed, 
will  be  found  to  be  a part  of  the  neck  of  the  bladder,  sphacelated  and 
separated.  These  suspicions  may  be  confirmed  or  annulled  by  simply 
passing  a catheter  into  the  bladder,  and  introducing  a finger  into  the 
vagina,  along  the  course  of  the  urethra ; if  any  portion  of  the  catheter  can 
be  felt  naked  through  the  vagina,  a fistulous  orifice  has  been  formed,  and 
the  treatment  under  such  circumstances  must  be  regulated  according  to 
the  common  principles  of  surgery. 

Pressure  on  the  nerves. — Occasionally  the  nerves  suffer ; the  great  sci- 
atic, which  lies  over  a part  of  the  sacro-iliac  synchondrosis,  is  especially 
exposed  to  pressure,  unless  there  be  a large  cushion  of  fat  in  the  pelvic 
cavity.  Pressure  on  this  nerve,  under  labour,  produces  great  pain,  numb- 
ness, and  cramps,  and  sometimes  a partially  paralytic  state  after  delivery. 
Nerves  in  themselves  do  not  possess  much  restorative  power,  although 
usually  they  regain  their  healthy  state  after  labour.  I never  knew  an 
instance  in  which  permanent  paralysis  existed  as  a consequence  of  injury 


CONSEQUENCES  OF  LINGERING  LABOUR.  279 

done  to  a nerve  under  labour,  though  I have  known  pain,  numbness,  and 
inability  to  move  freely,  continue  for  many  weeks. 

Tumour  on  the  foetal  scalp. — When  a child  is  born  after  lingering 
labour,  the  head  having  been  considerably  compressed,  we  shall  usually 
find  a circumscribed  tumour  on  the  scalp,  at* the  vertex,  as  depicted  in 
Plate  XXX.  fig.  92,  Plate  XXXIII.  fig.  99,  Plate  XXXV.  fig.  104,  and 
Plate  XXXVI.  fig.  110.  Such  a swelling  has  been  often  supposed  to 
contain  fluid,  and  I have  known  it  proposed  to  be  punctured,  though 
I never  saw  the  practice  carried  into  effect.  There  is  a feeling  of  sub- 
dued fluctuation  in  the  tumour ; but  it  is  not  a morbid  growth  ; it  proceeds 
entire  from  the  collapse  of  the  bones,  owing  to  the  compression  which 
they  have  suffered.  Generally  speaking,  these  cases  do  very  well ; there 
is  no  fluid  present,  or  merely  a small  quantity  in  the  cellular  texture,  that 
does  not  require  to  be  let  out  by  an  operation.  As  the  brain  becomes 
more  developed,  or  regains  its  healthy  form,  the  bones  in  a few  days 
acquire  their  natural  position,  the  head  its  proper  shape,  and  the  tumour 
disappears.  It  is  only  necessary  to  apply  an  ovaporating  lotion  to  the 
part, — more,  perhaps,  for  the  sake  of  satisfying  the  mother,  than  for  any 
decided  advantage  likely  to  be  derived  from  its  use. 


* ' 


- * 


V ? 


* 


• 

' 

1 - 


Order  III.— OF  PRETERNATURAL  LABOUR. 


Plates,  XXXVIII.,  XXXIX.,  XL.,  XLI.,  XLII.,  XLIII.,  XLIV.,  XLV., 
XLVI.,  XLVII.,  XLVIII.,  XLIX.,  L. 


Hitherto  the  attention  has  been  confined  to  different  cases  of  head 
presentation ; but  as  there  is  scarcely  any  point  of  the  foetal  body  that  may 
not  present  in  labour,  those  cases  in  which  any  other  part  meets  the  finger 
than  the  head  have  been  classed,  after  Denman,  as  preternatural  labours ; 
of  these  by  far  the  most  frequent  is  the  presentation  of  one  or  both 
nates.* 

* Many  speculative  fancies  have  been  indulged  in,  designed  to  account  for  the  preponde- 
ranee  of  head  presentations;  and  gravitation  has  had  most  supporters.  It  was  supposed  that 
the  placenta  was  invariably  situated  at  the  fundus  uteri ; and  that,  the  foetus  being  suspended 
by  the  funis  umbilicalis,  its  head,  which  is  the  heaviest  part,  naturally  inclined  downwards ; 
especially  as  in  the  younger  embryo  the  umbilicus  is  comparatively  so  near  to  the  pubes. 
This,  however,  cannot  produce  the  influence  ascribed  to  it;  because,  during  at  least  the  latter 
half  of  utero-gestation,  the  foetus  is  not  suspended  by  the  funis,  which  indeed  is  too  long  to 
admit  of  such  a possibility  ; — because  the  placenta  is  not  always,  nor  indeed  generally,  im- 
planted at  the  fundus  uteri, — being  sometimes  even  situated  upon  the  cervix,  or  over  the 
mouth  of  the  womb  itself;  in  which  ease,  at  no  period  of  pregnancy  would  the  foetus  be  sus- 
pended under  the  upright  posture  of  the  body  ; — and  because  the  funis  is  sometimes  found 
coiled  around  one  of  the  foetal  limbs ; which  accidental  position  must  influence  the  depending 
part,  even  if  the  embryo  were  actually  suspended.  These  and  other  facts  are  most  forcibly 
adduced  by  Dubois,  in  a paper  published  in  the  third  volume  of  the  Memoirs  of  the  Royal 
Academy  of  Medicine,  page  431,  to  overturn  the  opinion  that  gravitation  had  any  influence 
in  producing  the  presentation  of  the  head ; and  he  has  ascribed  the  general  situation  to  an 
instinctive  impulse  implanted  in  the  foetus,  which  inclines  it  to  take  the  most  favourable  posi- 
tion for  its  escape, — as  the  needle  points  mysteriously  to  the  pole.  But  such  a mode  of  rea- 

36 


282 


PRETERNATURAL  LABOUR. 


Two  orders. — Preternatural  labours  are  divided  into  two  orders;  the 
first  embracing  presentations  of  the  breech,  or  any  part  of  the  lower 
extremities ; and  the  second,  those  cases  in  which  the  child  offers  itself 
transversely.* 


1st.  PRESENTATION  OF  THE  BREECH  OR 
LOWER  EXTREMITIES. 

Breech  Presentation. — A woman  will  frequently  suspect  that  she  is 
about  to  have  a cross-birth,  as  it  is  called,  (for  all  preternatural  cases,  in 
common  parlace,  are  so  termed,)  if  she  have  suffered  some  peculiar  feel-  | 
ings  under  pregnancy,  such  as  she  has  not  previously  experienced,  or  if 
she  be  different  in  her  size  and  shape  from  what  she  had  been  on  former 
occasions.  But  on  such  supposed  indications  we  can  place  no  reliance,  i 
Inasmuch  indeed  as  the  child  lies  with  the  long  diameter  of  the  ovum  in 
a situation  perpendicular  to  the  trunk  of  the  body,  the  general  shape  of 
the  uterus  will  be  much  the  same  as  if  the  head  were  downward ; and 

. 

soning  and  illustration  cannot  be  considered  either  as  argumentative  or  conclusive;  it  is,  in 
fact,  completely  evading  the  question,  after  attempting  to  elucidate  it ; and  the  method  he  has 
taken  can  only  be  regarded  as  a cloak  for  human  ignorance.  It  would,  in  my  opinion,  be 
much  better  not  to  endeavour  to  explain  the  secrets  of  nature,  so  deeply  hidden,  but  to  content 
ourselves  with  referring  this  also  to  a general,  though  not  invariable  law, — a part  of  the  great 
system  which  shows  the  design,  and  exemplifies  the  harmony,  that  reign  throughout  the 
whole  works  of  Providence.  M.  Virey,  (Revue  Medicale,  vol.  ii.  1833,  p.  397,)  indeed,  has 
stated  that  in  those  pregnant  animals  of  the  rnultiparient  kind  which  he  has  dissected,  he, 
always  found  in  the  horns  of  the  uterus  the  snouts  pointing  to  the  vulva  ; that  in  a gravid  viper  ' 
which  he  opened,  all  the  young,  eight  in  number,  were  placed  in  the  direction  with  their,; 
mouths  towards  the  external  parts;  that,  in  the  egg,  the  head  is  always  directed  to  the  large , 
end, -and  that  that  end  is  extruded  first ; and  that  the  same  obtains  with  regard  to  the  ova  of 
fishes.  We  all  know  that  the  larvae  of  insects  escape  with  their  head  first, — that  the  chrysalis 
eats  through  its  shell,  and  the  caterpillar  through  its  silky  covering  ; and  we  see,  therefore, 
one  common  law  regulating  the  whole  of  nature's  operations. 

* The  average  frequency  of  breech  presentations  has  been  variously  stated,  as  different 
tables  have  been  taken  for  the  guide.  The  returns  from  the  Muternite  in  Paris,  published  by 
Dubois,  (Dictionaire  de  Medecine,  second  edition,  vol.  i.  p.  370,)  calculated  from  20,517  deli- 
veries, show  one  in  33 — 30  births.  Collins  (Practical  Treatise  on  Midwifery,  p.  40)  gives  the 
average  of  “ preternatural  presentations,”  during  his  mastership  of  seven  years  at  the  Dublin 
Lying-in  Hospital,  at  one  in  thirty.  The  number  of  children  born  in  this  period  was  16,654. 
The  tables  which  I have  kept  of  the  patients  of  the  Royal  Maternity  Charity  in  London, 
delivered  under  my  own  superintendence,  since  the  year  1827  to  this  date,  Sept.  1st.  1840, 
amounting  to  27,739  cases,  and  28,043  births,  give  an  average,  as  nearly  as  possible,  of  one 
in  thirty-five.  All,  these,  however,  include  twins  and  premature  labours,  in  which  class  of 
cases  irregular  presentations  arc  more  frequent  than  in  single  births  or  labours  at  full  iime. 


BREECH  PRESENTATION. 


283 


there  is  not  one  symptom  by  which  we  are  able  to  detect  that  the  breech 
will  present,  previously  to  the  commencement  of  labour.  It  might  be 
supposed,  perhaps,  if  the  uterine  parietes  were  unusually  thin,  and  the 
woman  much  attenuated,  that  we  should  be  able  to  feel  the  hard  globular 
head  towards  the  fundus;  and  that  this  might  lead  us  to  believe  the  breech 
would  present  in  labour;  but  any  suspicions  drawn  from  such  a source 
must  be  very  liable  to  error;  for  it  is  far  from  easy  to  distinguish  the 
head  by  the  hand  applied  externally : and  the  labour  must  be  somewhat 
advanced  before  we  can  ascertain  that  the  breech  is  offering  itself  at  the 
pelvic  brim. 

Causes. — Many  accidental  causes,  which  may  be  avoided,  have  been 
supposed  to  produce  cross-births ; such  as  violent  exercise,  the  shaking 
of  a carriage,  different  postures  of  the  body,  and  especially  that  in  which 
the  hands  are  frequently  raised  above  the  head, — as  in  the  case  of  females 
employed  in  shops.  It  is  now,  however,  fully  known  that  such  circum- 
stances influence  in  no  degree  the  situation  of  the  infant  in  the  womb  ; for 
women  who  confine  themselves  closely  to  the  sofa  during  the  whole  of 
gestation,  are  liable,  equally  with  those  who  take  active,  or  even  violent 
exercise,  to  have  their  children  present  prefternaturally.  Some  women, 
indeed,  from  original  formation,  or  other  at  present  inexplicable  causes, 
appear  particularly  obnoxious  to  this  mischance,  and  it  has  occurred  to 
me  to  know  many  instances  of  such  peculiarity.* 

Irregular  presentations  are  popularly  believed  to  be  more  frequent 
among  the  lower  than  the  higher  classes.  I have  myself  reason  to  think 
that  this  observation  is  not  correct.  In  the  aggregate,  there  certainly 
are  more  cases  met  with  among  the  poor  than  among  the  rich;  but 
not  more  than  the  relative  numbers  of  the  two  orders  would  lead  us  to 
expect. 

P articular  position  of  the  child. — Under  a breech  presentation,  the  child 
may  be  variously  placed  in  utero ; with  the  back  towards  the  abdominal 
muscles  of  the  mother,  and  the  face  towards  the  spine, — with  the 'face 
anteriorly,  and  the  back  towards  the  spine, — with  one  ilium  looking 
towards  the  promontory  of  the  sacrum,  the  other  towards  the  symphysis 
pubis,  and  the  face  to  one  or  other  side  of  the  mother, — and,  lastly,  in  a 
diagonal  direction,  one  ilium  being  situated  against  the  sacro-iliac  sym- 
physis, the  other  behind  the  groin  of  the  opposite  side.  The  first-named 
position  is  the  most  usual,  with  the  back  towards  the  abdominal  muscles, 
the  face  towards  the  spine,  with  the  right  side  towards  the  left  side  of  the 
pelvis,  and  the  left  side  towards  the  right,  Plate  XXXVIII.  fig.  115,  and 
the  foetal  body  is  inclined,  in  a slight  degree,  towards  a diagonal  posi- 


* See  in  confirmation  Collins,  Op.  Cit,  p.  40. 


284 


PRETERNATURAL  LABOUR. 


lion,  one  of  the  nates  being  a little  in  advance  of  the  other ; so  that  the 
child  does  not  present  itself  with  the  anus  directly  over  the  centre  of  the 
os  uteri  but,  a little  to  one  side. 

Progress  of  the  labour. — When  the  breech  presents,  the  labour  com- 
mences exactly  in  a similar  manner  as  though  the  head  offered  itself : pre- 
viously to  the  accession  of  uterine  pains,  the  womb  subsides  lower  in  the 
person, — partly  in  consequence  of  the  cervix  uteri  being  received  into  the 
cavity  of  the  pelvis,  and  partly  in  consequence  of  the  contraction  going  on 
in  the  uterine  volume  itself.  The  pains  at  first  appear  weak,  slow,  and  at 
long  intervals ; but  they  gradually  increase  both  in  frequency  and  strength. 
Under  these  contractions  the  os  uteri  dilates,  the  membranes  protrude 
through  it  into  the  vagina;  after  an  uncertain  time  they  rupture,  and  the 
breech  of  the  child  occupies  the  brim. 

In  illustration  of  the  passage  of  the  child  through  the  pelvis,  I will  in- 
stance the  case  most  commonly  met  with — viz.  where  the  face  is  looking 
towards  the  spine,  and  one  ischium  is  somewhat  preceding  the  other. 
The  os  uteri  being  entirely  dilated,  the  membranes  broken,  and  the  breech 
entering  the  pelvis,  it  is  propelled  downwards  with  each  pain,  and  recedes 
a little  in  the  interval,  till  it  comes  to  press  on  the  outlet  of  the  pelvis. 
Now,  inasmuch  as  the  greatest  width  of  the  breech  is  from  side  to  side,  it 
is  evident  that  the  foetus  has  already  adapted  itself  to  the  capacity  of  the : 
pelvic  brim,  in  the  situation  most  favourable  for  its  entrance  into  the 
cavity;  but  when  it  presses  on  the  outlet,  its  long  diameter  is  opposed  to' 
the  short  diameter  of  the  outlet;  and  in  this  situation  a slight  turn  is  ef- 
fected ; — though  not  so  complete,  perhaps,  as  the  head  takes  under  a na- 
tural presentation ; — one  of  the  ilia  sweeping  the  cavity  of  the  sacrum, 
and  the  other  appearing  under  the  arch  of  the  pubes.  In  this  way  it  is 
propelled,  distending  the  perineum  considerably,  till  the  breech  is  entirely 
in  the  world.  Plate  XXXVIII.  fig.  11G.  The  legs  pass  doubled,  with' 
the  toes  up  towards  the  chest,  and,  as  soon  as  they  are  expelled  as  far  as 
the  knees,  they  are  usually  thrown  out  of  the  vagina  by  the  action  of  its  > 
fibres.  When  the  body  of  the  foetus  is  thus  passing  through  the  outlet  of 
the  pelvis,  after  the  turn  is  effected,  the  shoulders  are  entering  the  brim,  | 
either  with  their  long  diameter  in  the  direction  of  the  lateral  diameter  of 
the  brim,  or  a little  diagonally.  As  the  foetal  body  traverses  the  cavity, 
the  hands  are  slipped  up  towards  the  head,  so  that  the  axillae  and  the  inner 
surface  of  the  arms  come  into  direct  contact  with  the  mother’s  structures. 
The  pains  continuing,  and  the  foetus  being  propelled  lower,  the  axillae 
come  to  press  against  the  interior  surface  of  the  ischia : another  turn  is 
then  effected ; by  means  of  which,  one  peeps  up  under  the  arch  of  the  ; 
pubes,  and  the  other  is  directed  along  the  sacral  cavity  and  the  perineum. 
Here,  again,  the  shoulders  are  thrown  into  the  best  possible  position  for 


rL^xxvm. 


BREECH  PRESENTATION. 


285 


their  escape,  and,  at  the  same  time,  the  head  is  entering  the  brim  in  the 
most  favourable  situation  for  its  transit ; but  on  arriving  at  the  outlet,  the 
chin  hitching  on  the  internal  surface  of  one  ischium,  the  occiput  on  the 
other,  the  greatest  diameter  of  the  head  is  in  the  direction  of  the  shortest 
diameter  of  the  outlet;  and  it  is  as  impossible  that  it  can  pass  without 
being  changed  in  situation,  as  it  would  be  while  the  face  looked  to  either 
ischium  under  an  original  presentation  of  the  vertex.  It  is  necessary, 
therefore,  that  a third  turn  should  take  place;  and  this,  like  the  previous 
turns,  is  accomplished  by  the  expulsive  action  of  the  uterus  above,  being 
resisted  by  the  formation  of  the  bones  below.  The  face  is  thrown  into 
the  hollow  of  the  sacrum,  the  occiput  under  the  arch  of  the  pubes,  and  the 
head  is  expelled  with  the  face  sweeping  the  perineum.  Usually  the  arms 
remain  by  the  side  of  the  head  until  the  child  is  quite  born,  if  no  assistance 
be  rendered. 

The  case  next  in  frequency  is,  where  the  face  looks  anteriorly,  and  the 
back  towards  the  spine.  The  same  effect  is  produced  by  the  expulsive 
efforts  as  in  the  former.  The  breech  descends  to  the  outlet  of  the  pelvis, 
receding  and  advancing  alternately,  as  the  pains  return  and  intermit ; a 
slight  turn  is  effected ; one  of  the  ilia  appears  under  the  arch  of  the  pubes, 
the  other  traverses  the  perineum ; the  breech  and  legs  are  born ; the 
shoulders  pass  the  brim,  and  descend  until  they  press  upon  the  structures 
at  the  outlet ; one  of  the  axillae  is  then  directed  under  the  arch  of  the 
pubes,  the  other  follows  the  curve  of  the  sacrum,  and  the  head  is  propelled 
into  the  cavity  of  the  pelvis,  with  the  face  looking  to  one  side  and  the  oc- 
ciput to  the  other.  It  might,  ci  priori , be  supposed  that  as  the  face  was 
originally  lying  towards  the  abdominal  muscles  of  the  mother,  the  occiput 
would  be  expelled  along  the  hollow  of  the  sacrum,  and  the  face  escape 
anteriorly ; but  this  is  not  the  case ; for  when  the  shoulders  are  external 
and  the  head  is  in  the  pelvis,  the  face  is  directed  to  one  side  or  the  other, 
exactly  as  when  the  child  presents  with  the  face  towards  the  spine  in  the 
first  instance ; and  a precisely  similar  turn  is  effected,  the  face  being  thrown 
backwards ; so  that  the  foetus,  in  its  transit,  makes  a semi-circular  rotation, 
the  face  being  placed  forwards  at  the  commencement  of  labour,  and  being 
expelled  through  the  outlet  traversing  the  sacrum  and  perineum.  I believe 
that  in  no  instance,  if  the  case  were  left  entirely  to  nature — provided  the 
child  and  pelvis  were  of  common  size  and  form — would  the  face  be  ex- 
pelled under  the  arch  of  the  pubes. 

If  the  breech  is  offering  itself  diagonally,  exactly  the  same  occurrences 
;ake  place  which  I have  just  described ; for  the  pelvis  is  almost,  if  not 
juite,  as  wide  from  the  sacro-iliac  synchondrosis  to  the  opposite  groin,  as 
rom  side  to  side.  But  when  the  child’s  abdomen  is  directed  to  one  ilium, 
ind  the  back  towards  the  other,  the  long  diameter  of  the  breech  is  in  the 


286 


PRETERNATURAL  LABOUR. 


direction  of  the  short  diameter  of  the  pelvic  brim,  and  the  probability  is 
that  it  would  not  pass  with  the  same  ease  as  in  the  former  case ; but  thal 
it  would  be  turned  a little  to  one  side  before  it  entered  the  cavity.  Thei 
changes  in  position  just  adverted  to  then  take  place,  and  expulsion  is  ac- 
complished in  the  same  way  as  if  it  offered  in  the  more  usual  direction  ol 
breech  presentations. 

Breech  presentations  with  feet. — It  is,  however,  not  only  breech  presen-l 
tations  that  form  the  first  order  of  preternatural  labours : one  or  both  feet 
may  present,  Plate  XXXIX,  fig.  117,  or  a foot  and  the  breech  together, 
or  both  feet  and  the  breech,  or  a knee  and  a foot,  Plate  XXXIX,  fig.  118, 
or  both  knees.  Thus  even  this  apparently  simple  order  of  preternatural 
cases  admits  of  a great  variety. 

It  is  evident  that  there  will  not  be  more  difficulty  when  the  knees  pre- 
sent, than  in  a breech  presentation — probably  not  so  much ; because  the 
parts  are  expanded  more  gradually,  the  body  of  the  child  forming  more  of 
a cone.  But  although  it  is,  perhaps,  not  so  painful  a labour  as  when  the 
legs  are  doubled  up  towards  the  abdomen,  still  it  is  more  dangerous  to  the 
child,  since  there  must  be  more  pressure  on  the  funis  umbilicalis  when  the 
upper  part  of  the  body,  or  the  head,  is  passing,  in  consequence  of  the  parts 
not  having  been  so  completely  opened  as  if  the  breech  had  previously  es- 
caped double. 

If  the  breech  and  one  or  both  feet  should  present,  which  is  by  no  means 
unusual,  more  space  would  be  occupied,  and  more  time  would  be  gene- 
rally taken  up,  than  when  the  breech  presented  singly;  but  still  the  same 
action  would  go  on,  and  the  same  effect  be  produced,  provided  the  pelvis 
were  sufficiently  large.  One  foot,  or  perhaps  both,  would  be  protruded 
externally  before  the  breech,  the  same  turns  would  be  effected,  and  the 
labour  would  most  likely  be  completed  by  nature,  without  much  assist- 
ance. j 

Conduct  under  breech  presentation. — In  cases  of  breech  presentation  a 
great  deal  more  attention  is  required  of  the  obstetrician  than  under  a na- 
tural labour,  as  well  for  the  protection  of  the  woman’s  parts,  as  for  the 
preservation  of  the  child’s  life ; for  the  infant  is  always  placed  in  greater 
or  less  jeopardy  from  the  pressure  which  must  take  place  on  the  funis 
umbilicalis  during  the  passage  of  the  shoulders  and  the  head.  More  care 
is  requisite  to  prevent  injury  to  the  woman’s  structures ; because,  in  natu- 
ral labour,  when  the  head  is  born, — since  that  possesses  the  largest  cir- 
cumference of  any  portion  of  the  foetal  body, — the  passages  are  generally 
sufficiently  distended  by  it  to  permit  the  easy  transit  of  the  other  parts. 
But  when  the  breech  comes  first,  being  smaller  in  diameter  than  the 
shoulders,  it  only  causes  a partial  dilatation;  the  shoulders  pressing  upon 
the  parts  subsequently,  distend  them  still  more,  and  at  last  the  head,  which 


TI.XXX3X 


S'iriucZa.Ti'.rJjiit/i, 


BREECH  PRESENTATION. 


237 


is  the  largest  body,  has  still  farther  to  open  them ; so  that  we  must  conti- 
nue our  support  to  the  perineum  until  the  infant  is  entirely  in  the  world. 
In  natural  labour,  however,  it  is  only  necessary  to  protect  these  structures 
while  the  head  and  shoulders  are  making  their  escape. 

The  first  duty  we  have  to  perform,  is  to  ascertain  the  presentation  ; and 
it  is  a matter  of  the  greatest  possible  consequence  that  we  should  detect 
a breech  case  early  in  labour,  lest  we  should  confound  it  with  the  head, 
and  more  particularly  with  the  shoulder ; for  there  are  many  points  of 
resemblance  between  the  breech  and  both  these  parts;  and,— while  a 
breech  case  requires  comparatively  little  assistance,— under  a shoulder 
presentation,  the  performance  of  an  operation  both  difficult  and  dangerous 
becomes  necessary  to  accomplish  delivery. 

No  indication  authorizing  a supposition  that  the  breech  presents,  can  be 
gathered  from  the  mode  in  which  the  membranes  protrude  into  the  vagina, 
which  is  usually,— as  when  the  head  offers,— in  the  form  of  the  large  end 
of  an  egg.  But  the  breech  may  be  discriminated  from  the  head  and  other 
parts,  as  soon  as  it  can  be  felt  by  some  marks  both  positive  and  negative ; 
and  I shall  now  only  point  out  the  diagnostic  marks  with  reference  to  the 
head,  reserving  those  connected  with  the  shoulder  for  future  considera- 
tion. The  breech  is  not  so  round,  nor  so  hard,  nor  so  strongly  ossified, 
as  the  head  it  is  not  divided  into  compartments  by  sutures  and  fonta- 
nelles;  on  the  contrary,  it  possesses  two  hemispheres;  it  is  more  fleshy, 
softer  to  the  finger,  and  is  not  so  resistant  to  that  touch ; we  may  most 
probably  also  detect  the  chink  between  the  thighs,  the  organs  of  genera- 
tion, and  the  anus.  If  we  have  fully  ascertained  the  existence  of  these 
negative  and  positive  marks,  and  especially  if  we  have  detected  the  organs 
of  generation,  male  or  female,  and  the  anus,  it  is  impossible  that  we  can 
mistake  the  breech  for  the  head. 

These  points  must  be  determined  previously  to  the  rupture  of  the  mem- 
branes ; and  our  examination  must  be  made  with  the  greatest  care,  and 
m the  interval  of  uterine  contraction,  lest  we  should  break  the  membranes ; 
for  it  is  even  of  greater  importance,  in  the  case  we  are  considering,  that 
we  should  preserve  the  watery  cyst  entire,  than  if  it  were  a head  presen- 
tation. When  we  first  make  an  examination,  if  the  nates  be  the  most 
depending  part,  and  we  ascertain  that  there  is  not  that  characteristic  feel 
which  the  head  supplies,  we  may  be  in  doubt  as  to  whether  the  shoulder 
or  breech  be  at  the  brim.  If  so,  we  should  pass  two  fingers  of  the  left 
hand,  during  the  absence  of  pain,  into  the  pelvis,  up  to  the  brim,  within 
the  os  uteri ; and  it  is  seldom  that  we  cannot,  in  this  way,  gain  the  infor- 
mation we  require.  Having,  then  positively  detected  the  breech,  there  is 
10  necessity  for  alarm, — we  are  not  to  suppose  that  the  woman  will  be 
endangered ; we  must  not  manifest,  in  our  manner,  either  agitation  or 


/ 


288 


PRETERNATURAL  LABOUR. 


anxiety ; — and  we  must  be  particularly  cautious  not  to  let  the  patient  hear 
“ a cross-birth  ” whispered  in  her  chamber,  because  she  will  certainly  be 
more  or  less  excited ; and  such  a shock  might  be  suddenly  impressed  as  to 
suspend  labour,  and  retard  it  for  a number  of  hours.  We  may,  then,  en- 
deavour to  evade  her  anxious  question,  whether  every  thing  is  right , by 
assuring  her  of  her  perfect  safety.  At  the  same  time,  it  is  desirable  that 
her  friends  should  be  informed  that  the  case  is  one  of  the  simplest  kind  of 
cross-births ; that  most  probably  no  operation  will  be  required,  but  that 
there  is  a great  chance — especially  if  it  be  a first  labour — that  the  child 
will  not  be  born  alive.  If  in  this  first  examination  we  are  quite  satisfied 
that  the  breech  presents,  but  not  able  to  detect  whether  the  abdomen  of 
the  child  is  situated  backwards  or  forwards,  it  is  neither  necessary  nor 
proper  that  we  should  be  constantly  making  examinations  for  the  purpose 
of  ascertaining  this  point.  It  is  right  that  we  should  be  a little  more  assi- 
duous in  our  attention  to  the  patient  than  if  the  head  presents,  but  not 
so  officious  as  to  alarm  her ; and  it  is  quite  requisite  that  we  should  not 
absent  ourselves  from  the  house.  We  may  occasionally  institute  an  exa- 
mination in  the  absence  of  pain,  to  watch  the  progress  of  the  dilatation  of 
the  os  uteri,  and  the  descent  of  the  membranes,  but  we  must  be  most 
careful  not  to  break  them,  although  they  should  appear  externally ; wait- 
ing even  then,  within  proper  limits,  for  their  spontaneous  rupture. 

The  membranes  having  broken,  and  the  breech  fully  occupying  the 
pelvic  cavity,  we  must  apply  our  hand,  guarded  by  a napkin, — in  the 
same  way  as  when  the  head  presents, — over  the  perineum,  and  support  it 
until  the  breech  and  legs  are  in  the  world ; and  as  soon  as  the  funis  has 
appeared  externally,  we  must  bring  down  a fold,  Plate  XL.  fig,  119,  in 
order  to  present  its  vessels  from  being  stretched.  It  has  been  shown  that 
the  umbilical  arteries  run  in  a twisted  direction  around  the  vein,  and  it  is  • 
a necessary  consequence  that  a compression  of  their  cavities,  and  a dimi- 
nution in  their  calibre,  would  take  place  quite  as  easily  from  a tightening 
of  the  cord,  as  from  actual  pressure  being  applied  to  it.  We  cannot  pre- 
vent the  direct  compression  which  the  funis  must  suffer  between  the 
child’s  head  and  the  pelvic  bones,  but  we  can  prevent  tension,  by  bring- 
ing down  a portion  as  a loop ; and  it  is  very  possible,  if  we  neglected 
this  precaution,  that,  as  the  body  was  being  expelled,  the  cord  would 
be  so  stretched  as  to  impede  the  circulation,  and  destroy  the  infant’s 
life. 

When  the  shoulders  are  about  to  pass,  it  is  our  duty  to  take  care  that 
they  are  offering  themselves  in  that  position  most  favourable  for  their  exit, 
and  if  they  be  not,  to  turn  one  under  the  arch  of  the  pubes,  and  the  other 
into  the  hollow  of  the  sacrum ; and  this  is  doubly  requisite,  not  only  for 
the  easy  transit  of  the  arms  themselves,  but  for  the  purpose  of  placing  the 


/•Vy  /Z>. 


ri.xij. 


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LIBRARY 
0/  THE 

?M,^rPSH  Y OF  tLL!NO!G 


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f.  '■ 


BREECH  PRESENTATIONS. 


289 


head  in  the  most  favourable  position  for  its  passage  through  the  brim. 
The  arms  being  brought  down,  we  may  direct  the  head  into  the  most 
easy  situation  for  its  escape,  taking  advantage  of  the  expulsive  action  of 
the  uterus  to  aid  our  gentle  endeavours.  When  the  head  is  fully  occupy- 
ing the  pelvis,  the  chin  being  within  one  ilium,  and  the  occiput  within  the 
other,  we  may  with  great  advantage  facilitate  the  turn  of  the  face  into 
the  hollow  of  the  sacrum,  by  placing  the  right  hand  on  the  back  of  the 
child,  the  left  on  the  abdomen;  the  first  two  fingers  of  the  right  hand  forming 
a crutch  around  the  neck.  We  may  then  support  the  perineum  with  the 
left  hand  ; as  the  head  is  passing,  we  may  turn  the  nape  of  the  neck  up 
under  the  symphysis  pubis,  as  on  a pivot ; bring  the  back  towards  the  mons 
veneris ; and  thus  assist  the  birth,  not  by  drawing  the  child’s  head  forcibly 
out,  but  merely  receiving  it  as  it  is  expelled  by  the  action  of  the  uterine 
and  vaginal  fibres.* 

The  child  being  born,  our  duties  are  merely  those  appertaining  to  com- 
mon labour ; we  must  wipe  its  face,  take  care  that  it  does  not  inhale  any 
of  the  mucus  about  the  parts,  separate  it  as  before  described,  dispose  of  it 
to  the  nurse  or  some  other  party,  and  then  make  an  examination  of  the 
uterine  tumour.  In  all  cases  of  breech  presentation,  it  is  right  that  a warm 
bath  and  other  resuscitating  means  should  be  in  readiness,  and  close  at 
hand,  in  order  that  the  best  chance  should  be  afforded  of  restoring  the 
child,  provided  animation  be  suspended. 

It  used  to  be  the  custom,  and  it  is  still  practised  by  some,  to  make 
traction,  as  soon  as  the  breech  is  in  the  pelvis,  and  before  the  nates  appear 
externally,  by  hooking  the  finger  first  in  one  groin,  and  then  in  the  other, 
and  to  bring  down  the  legs,  so  that  the  feet  might  pass  externally  as  early 
as  possible.  Dr.  William  Hunter  at  one  time  recommended  this  practice, 
and  he  was  by  no  means  a meddlesome  obstetrician.  The  object  of  the 
recommendation  was  to  save  the  patient  pain.  It  was  argued,  why  should 
we  suffer  the  woman’s  structures  to  be  so  much  distended  by  the  double 


* I have  been  called  upon  to  extract  the  head  in  many  cases,  where  it  was  supposed  that 
the  pelvis  was  distorted  or  the  head  preternaturally  large,  merely  because  the  previous  attend- 
ant  had  not  been  mindful  of  causing  the  head  to  pass  through  the  brim  with  its  long  diame- 
ter in  the  direction  of  the  long  diameter  of  the  brim,  but  had  brought  the  child  down  with  the 
face  backwards,  so  that  the  forehead  impinged  on  the  prominence  of  the  sacrum,  as  shown  in 
Plate  XL.  fig.  120,  or  forwards  against  the  symphysis  pubis  ; such  an  accident,  besides  entail- 
ing much  additional  pain  on  the  mother,  is  almost  certainly  followed  by  the  infant’s  death, 
from  the  pressure  to  which  the  cord  must  be  exposed.  It  may  be  prevented  by  paying  due 
regard  that  the  face  passes  through  the  brim  towards  one  or  other  ilium,  and  may  be  reme- 
died, when  it  has  taken  place,  by  turning  it  in  the  same  direction.  Placing  the  head  in  the 
most  favourable  position  for  its  passage  through  the  brim,  is  one  of  the  most  important  points 
in  the  management  of  a breech  case,  but  it  is  of  all  the  duties  appertaining  to  such  a case, 
perhaps,  the  one  most  frequently  neglected. 

37 


290 


PRETERNATURAL  LABOUR. 


breech,  when  we  have  it  in  our  power  easily  to  relieve  them  of  the  tension, 
by  bringing  down  the  feet,  and  allowing  them  to  be  expanded  more  gradu- 
ally; and  it  certainly  was  both  a very  plausible  argument,  as  well  as 
natural  conclusion.  But  the  result  of  this  practice  is  to  place  the  child’s 
life  in  imminent  hazard:  as  long  as  the  legs  are  turned  up  towards  the 
belly,  so  long  that  portion  of  the  funis  near  the  child’s  body  may  possibly  be 
protected  by  the  triangular  space  formed  between  the  two  thighs  and  the 
abdomen;  and  thus  a certain  degree  of  security  may  be  obtained. — - 
Again,  when  the  breech  has  been  expelled  doubled,  it  has  prepared  the 
way  for  the  exit  of  the  shoulders  and  head  much  more  completely  than 
when  it  has  passed  with  the  feet  foremost.  The  woman’s  structures 
must  be  subjected  to  a definite  degree  of  distention  during  the  passage  of 
the  head ; and  the  extent  to  which  that  distention  is  carried  is  not  influ- 
enced at  all  by  the  mode  in  which  the  breech  has  passed  the  pelvic  aper- 
tures. Is  it  not  better,  then,  that  she  should  suffer  the  pain  which  cannot 
be  prevented,  at  first,  with  the  chance  of  saving  the  child’s  life,  than  un- 
dergo it  afterwards,  when  there  is  a much  greater  probability  of  its  being 
born  dead  1 Dr.  Hunter,  indeed,  soon  saw  the  danger  of  interfering  in 
the  manner  he  first  adopted ; and  he  was  accustomed  to  say  in  his  lec- 
tures, that  when  he  used  to  extract  the  legs  before  the  breech,  he  lost 
almost  every  child ; but  when  ho  changed  his  mode  of  practice,  and  let, 
the  breech  pass  double,  and  did  not  allow  the  legs  to  escape  until  after  the 
knees  were  born,  he  was  much  more  fortunate  in  saving  the  children  ;* 
and  the  same  facts  have  been  established  by  subsequent  observers.  When 
the  body  is  expelled,  indeed,  and  the  arms  still  remain  within  the  pelvis, 
our  active  assistance  becomes  not  only  useful,  but  almost  necessary:  we 
mav  then  endeavour  to  relieve  the  parts  from  distention,  by  bringing  the 
arms  cautiously  down,  for  their  presence  in  the  vagina  can  be  of  no  ser-( 
vice;  they  cannot  preserve  the  funis  umbilicalis  from  pressure; — nay,  they,; 
are  actually  doing  harm,  for  they  take  up  room,  prevent  the  easy  descent 
of  the  head,  and  may  perhaps  themselves  press  upon  the  cord.  But  in  at- 
tempting to  bring  down  the  arms,  our  efforts  must  be  most  gentle;  and  we 
must  be  very  careful  to  direct  the  limbs  forward,  so  that  the  hands  should 
sweep  over  the  child’s  face.  If  we  were  to  turn  them  backwards,  we 
must  necessarily  break  or  dislocate  the  humerus — an  accident  that  might 
most  easily  happen,  from  the  imperfectly  ossified  state  of  the  bones.  That 
arm  placed  behind  the  symphysis  pubis  must  be  brought  down  first;  and 
this  is  generally  not  difficult  to  be  accomplished,  by  sliding  one  or  two 
fingers  perfectly  over  the  shoulder,  carrying  them  a little  way  along  the 
humerus,  and  carefully  directing  the  fore-arm  anteriorly ; this  being  ef- 


Scc  Mcrriinan’s  Synopsis,  p.  71;  note  of  Dr.  Hunter’s  MS.  Lectures. 


Pl.XLI 


nxLir. 


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•‘LIBRARY  ’ . • vy:  - -,  ^efl 

■'!■  1 HE  •’  ' ' •'•■.'••  :••••,'•  ••  * 'V*-'V 

i : RS-j  I i Of  ILUMOIS 


* . ** 

• X * : • 


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KNEE  PRESENTATIONS. 


191 


fected,  we  may  bring  the  child’s  body  forward,  so  that  the  side  of  the 
neck  should  be  applied  closely  under  the  symphysis  pubis,  introduce  two 
fingers  of  the  left  hand  back  towards  the  sacrum,  and  in  the  same  tender 
manner  extract  the  other  arm.  Plate  XLI.  fig.  121.* 

The  parts  being  now  relieved  from  tension,  the  head  pressing  some- 
what on  the  outlet  of  the  pelvis,  we  way  favour  the  inclination  of  the  face 
into  the  hollow  of  the  sacrum  by  the  means  just  recommended;  and  if 
there  be  any  difficulty  in  so  doing,  we  may  pass  a finger  into  the  mouth 
of  the  child,  Plate  XLI.  fig.  122,  depress  the  chin,  and  give  the  head  the 
requisite  turn.  Let  us  not,  however,  forget  the  delicate  structures  on 
which  we  are  operating : let  us  remember  that  the  bones  are  not  strong 
and  solid,  but  are  easily  broken;  that  there  is  a symphysis  in  the  centre 
of  the  jaw;  that  we  may  either  dislocate  the  articulation,  separate  the 
symphysis,  or  break  the  bone  itself.  Every  practitioner  is  aware  how 
tenderly  conducted  should  be  the  examination  of  an  infant’s  body  after 
birth ; and  quite  as  gentle  should  be  our  attempts  to  relieve  it  during 
labour. 

Under  a breech  presentation,  after  the  liquor  amnii  has  been  avacuated, 
the  meconium  is  frequently,  but  by  no  means  invariably,  squeezed  out  of 
the  rectum,  by  the  mechanical  pressure  sustained.  This  circumstance 
has  therefore  been  noted  as  a symptom  of  breech  presentation.  It  is  dan- 
gerous to  rely  on  this  occurrence  for  an  indication ; both  because  it  is  not 
universal  in  breech  presentations,  and  also  because  it  may  take  place 
under  other  positions  of  the  foetus.  Besides,  it  cannot  appear  until  after 
the  rupture  of  the  membranous  cyst ; and  it  is  far  better  and  safer  to  trust 
to  the  knowledge  gained  by  a minute  examination  of  all  those  points  of 
the  foetal  body  which  can  be  embraced  by  the  finger,  than  to  any  acci- 
dental sign. 

Knee  Presentations  next  come  under  consideration.  I will  suppose 
that  the  child  is  at  the  brim  of  the  pelvis ; that  the  labour  in  the  first  in- 
stance is  going  on  pretty  well — much  the  same  as  if  the  head  or  breech 
presented.  The  os  uteri  opens,  the  membranous  bag  somewhat  protudes — 
perhaps  in  the  form  of  the  finger  of  a glove,  instead  of  assuming  the  cha- 


* Denman,  chap.  xiv.  sect.  3,  says — “ It  has  been  esteemed  by  some  a very  injudicious 
practice  to  bring  down  the  arms  of  the  child;  these  being  turned  along  the  head,  preventing 
in  their  opinion,  that  contraction  of  the  os  uteri  round  the  neck  of  the  child,  which 
would  be  an  impediment  to  its  complete  deliverance.”  Such  fears  are  merely  hypothetical. — 
I never  knew  the  occurrence  dreaded  take  place  so  as  to  retard  the  child’s  passage.  When 
the  undilated  state  of  the  uterine  mouth  offers  much  impediment  to  the  birth  afler  the  body 
is  born,  it  is  by  girding  the  upper  part  of  the  head  just  above  the  nasal  bones,  as  is  well 
described  by  Merriman,  Synopsis,  p.  76. 


292 


PRETERNATURAL  LABOUR. 


racter  of  an  egg ; but  this  is  not  always  the  case.  Upon  making  our  ex- 1 
amination  at  the  commencement  of  labour,  we  detect  a small  round  sub- 
stance, with  a flattened  surface,  possessing  the  characteristics  neither  of 
the  head  nor  the  breech.  We  are  then  quite  sure  neither  of  these  parts 
present;  but  we  may  not  be  so  certain  whether  it  be  a leg  or  an  arm  that 
meets  our  finger. 

Plate  XXXIX.  fig.  118,  shows  a knee  and  foot  presenting,  and  a fold 
of  the  funis  prolapsed. 

If  one  or  both  knees  offer,  the  case  will  usually  be  terminated  by  the; 
natural  efforts;  but  if  it  be  an  elbow  presentation,  under  which  the  child! 
lies  transversely,  we  must  change  its  position  before  delivery  can  be  effect- 
ed. It,  therefore,  becomes  a matter  of  the  greatest  consequence,  that  we  j 
should  discriminate  between  the  patella  and  olecranon;  and  I shall  men-i 
tion  the  distinctive  marks,  when  on  the  subject  of  transverse  presentations.: 

The  knees  will  descend  into  the  pelvis ; and  the  legs  will  drop  out  of  I 
the  vagina,  earlier  than  if  the  thighs  had  been  bent  up  towards  the  abdo- 
men; the  breech  of  the  child  will  be  expelled;  the  funis  umbilicalis  will 
have  lost  its  protection  ; and  the  infant  will  be  in  great  danger  of  strangu-  j 
la  tion. 

Footling  Presentation. — Again,  one  or  both  feet  may  present,  the] 
breech  being  easily  distinguishable  by  the  finger,  or  lying  perfectly  out  of; 
the  reach  of  a common  examination.  Plate  XXXIX.  fig.  117. 

When  we  feel  the  digital  extremity  of  the  limb, — since  there  is  no  part! 
of  the  child’s  body  but  the  hand  with  which  it  can  possibly  be  confound- 1 
ed, — it  becomes  our  duty  to  discriminate  between  the  two,  for  reasons 
previously  more  than  once  inculcated;  and  this  we  can  generally  do  be- 
fore the  membranes  rupture.  The  foot  is  known  by  the  rounded  instep,' 
by  the  prominent  heel,  by  the  toes  being  all  in  one  line,  and  by  no  one  of- 
the  digits  being  an  opponent  to  the  others.  When  the  hand  is  at  the  pel-, 
vie  brim, — as  I shall  hereafter  state, — we  feel  the  flattened  wrist  and  palm,, 
the  thumb  an  opponent  to  the  fingers,  the  fingers  of  different  lengths,  and 
the  absence  of  the  marks  just  described. 

Under  presentation  of  the  feet,  the  labour  is  usually  rather  lingering, 
and  the  dilatation  of  the  passages  goes  on  but  slowly;  nevertheless,  this 
forms  no  excuse  for  hurry  or  interference:  we  must  wait  a moderate  time 
for  the  descent  of  the  child,  and  allow  nature  to  accomplish  her  intention 
unaided;  unless,  indeed,  there  be  danger,  or  some  urgent  reason  for  acce- 
lerating the  labour.  Should  delay  induce  us  to  interfere,  or  should  symp- 
toms of  danger  supervene  we  must  take  one  foot,  or  both,  between  two' 
fingers  of  the  left  hand,  and,  by  a little  traction,  bring  down  the  legs ; and 
then  we  have  made  the  case  one  of  the  most  simple  preternatural  labours. 


FOOTLING  PRESENTATIONS. 


293 


Circumstances  requiring  assistance  under  a breech  presentation. — 
Many  accidents  may  happen  during  the  progress  of  labour  under  a breech 
presentation,  independently  of  exhaustion  from  a long  continuance  of  pain- 
ful efforts,  which  will  require  that  delivery  should  be  accelerated  ; and 
some  of  these  originate  in  the  mother’s  system,  others  in  the  child’s.  Thus 
haemorrhage,  convulsions,  or  syncope,  may  induce  us  to  terminate  the  la- 
bour; and  delivery  is  generally  more  easily  accomplished  than  when  the 
head  presents ; for  we  are  then  compelled  either  to  introduce  the  hand 
into  the  uterus,  and  change  the  position  of  the  foetus,  or  to  apply  the  for- 
ceps, or  use  the  perforator,  if  that  dreadful  instrument  be  required  to  save 
the  mother ; but  when  the  breech  or  feet  present,  we  have  merely  to  make 
extraction  by  the  leg,  provided  it  be  easily  brought  down,  or  by  surround- 
ing the  groin  with  a finger  or  blunt  hook, — as  will  be  more  particularly 
described  subsequently. 

Danger  to  the  child’s  life  would  also  induce  us  to  expedite  the  termina- 
tion of  the  labour. 

We  are  not  likely  to  ascertain  that  the  child  is  in  jeopardy  until  after 
the  breech  is  expelled ; but,  when  the  body  is  half  born,  our  indication 
may  be  taken  partly  from  the  state  of  pulsation  in  the  cord,  and  partly 
from  a futile  attempt  at  respiration  being  made  while  the  head  still  remains 
either  in  the  uterus  or  vagina.  I have  already  directed  that  as  soon  as 
the  umbilicus  has  appeared  externally,  a loop  of  the  funis  should  be  brought 
down,  to  prevent  tension  on  its  vessels ; and,  at  the  same  time,  an  obser- 
vation may  be  made  on  the  rapidity  and  strength  of  the  foetal  circulation. 
If  the  arteries  of  the  funis  are  beating  freely,  firmly,  and  equably,  about 
one  hundred  strokes  in  a minute,  the  child  is  in  no  present  danger,  and  we 
need  not  accelerate  the  labour  for  its  sake ; for  by  so  acting  we  might 
leave  the  uterus  uncontracted,  and  occasion  an  attack  of  haemorrhage. 
But  if,  on  the  contrary,  the  circulation  be  languid  ; or  if  the  beats  be  very 
rapid,  small,  feeble,  tremulous,  or  intermittent,  some  impediment  exists  to 
the  transmission  of  the  blood  through  the  cord,  and  the  child’s  life  is  in 
imminent  hazard. 

The  other  indication  implying  danger  to  the  child,  is  an  abortive  at- 
tempt at  breathing  before  the  head  is  in  the  world  ; and  this  is  known  by 
a sudden  spasm  of  the  diaphragm  and  abdominal  muscles,  repeated  at 
uncertain  intervals.  It  would  appear  almost  incredible  that  the  infant 
should  endeavour  to  respire  while  the  face  is  closely  embraced  by  the 
maternal  structures,  and  when  it  can  inhale  nothing  but  the  uterine  dis- 
charges: such,  however,  I have  witnessed  on  numerous  occasions.  Tltis 
convulsive  effort  is  never  observed  so  long  as  the  circulation  along  the 
funis  is  carried  on  with  vigour;  because,  while  the  child’s  wants  can  be 
supplied  through  the  medium  of  the  placenta,  there  is  no  necessity  for 


294 


PRETERNATURAL  LABOUR. 


calling  forth  the  hitherto  dormant  function  of  the  lungs ; but  when  tha 
source  is  cut  off,  a fresh  action  is  requisite  for  the  continuance  of  life 
This  gasp,  then,  is  indicative  of  danger,  and,  together  with  a declining 
state  in  the  power  of  the  circulation  through  the  umbilical  vessels,  wouk 
induce  us  to  expedite  the  delivery,  lest  the  foetus  should  perish  in  transitu 
In  using  our  extractive  means,  however,  we  must  ever  remember  the  sen 
sibility  of  the  mother’s  organs,  and  the  delicacy  of  the  foetal  body.  Vio 
lence  may  do  irreparable  injury ; and  great  exertion  even,  in  the  cast 
under  consideration,  is  inadmissible. 

Difficult  breech  presentations. — Having  become  acquainted  with  tta 
mechanism  of  head  and  breech  presentations,  and  the  difficulties  that  are 
sometimes  met  with  under  natural  labour,  the  student  may  readily  sup- 
pose that  delays  will  also  occur,  and  that  impediments  will  exist  to  the 
easy  passage  of  the  foetus,  when  the  nates,  or  any  part  of  the  lower  ex- 
tremities, offer  themselves  at  the  pelvic  brim. 

All  the  causes  referable  to  the  mother,  which  have  been  before  described 
as  producing  delay  under  natural  labour,  may  equally  occasion  difficulty 
when  the  breech  presents;  and  these  may  all  be  included  in  one  of  the 
two  general  heads — either  inefficiency  of  the  propelling  powers,  or  a dimi- 
nution of  space  in  the  passages.  . 

Inefficient  uterine  action. — It  is  not  unfrequently  remarked,  that  under 
breech  presentations,  after  the  rupture  of  the  membranes,  the  uterus  for? 
some  time  acts  more  feebly  than  in  natural  labour ; and  this  is  perhaps 
owning  to  the  breech  producing  less  pressure  or  irritation  upon  the  os  uteri 
than  the  harder  head  would  do : but  the  contractions  presently  become 
sufficiently  strong ; and  when  the  pelvic  cavity  is  pretty  well  occupied  by 
the  foetal  body,  and  the  perineum  somewhat  on  the  stretch,  the  pains  are^ 
fully  as  powerful  as  when  the  head  is  passing.  Such  cases,  then,  require- 
no  artificial  assistance ; nor  is  it  necessary  or  desirable  to  stimulate  the 
uterus  to  increased  action.  But  should  the  patient  have  been  debilitated 
by  previous  disease,  worn  down  by  excessive  discharges,  be  of  relaxed 
fibre,  or  have  borne  a great  many  children,  we  may  anticipate  a necessity 
for  some  extraordinary  aid.  Should,  then,  this  sluggishness  on  the  part 
of  the  propelling  powers  continue,  while  at  the  same  time  the  pelvis  pos- 
sesses sufficient  capacity,  and  the  soft  structures  have  acquired  a due  de- 
gree of  relaxation  and  distensibility,  it  is  right  that  we  should  endeavour, 
by  the  means  already  mentioned,  (p.  165  et  seq.)  to  increase  the  tone  of  the 
uterus,  and  supersede  the  necessity  for  manual  interference  ; — such  are, 
warm  diluents,  taken  internally;  gentle  friction,  with  slight  pressure,  over  the 
abdomen ; change  of  posture ; and  should  the  arterial  system  also  be  acting 
with  diminished  energy — we  may  have  recourse  to  stimuli.  The  ergot 


BREECH  PRESENTATIONS. 


295 


of  rye,  as  a general  rule,  is  perhaps  inadmissible ; but  if  it  be  exhibited,  the 
cautions  before  noted  must  not  be  lost  sight  of. 

Presuming,  then,  the  case  under  treatment  is  one  in  which  such  circum- 
stances obtain  as  I have  just  specified,  and  the  means  recommended  have 
not  the  desired  effect,  it  next  becomes  a question  whether  we  are  war- 
ranted in  resorting  to  delivery  by  art.  To  answer  this  question,  many 
fircumstances  must  be  taken  into  consideration,  which  have  been  before 
sufficiently  dwelt  on;  but  since  artificial  delivery  under  a breech  presen- 
ation  is  for  the  most  part  easier  than  when  the  head  offers,  it  may  be 
illowable,  and  perhaps  advisable,  to  use  the  means  we  are  in  possession 
)f  rather  earlier  than  if  the  presentation  were  natural;  provided,  indeed,  no 
’isk  would  be  incurred  of  injuring  the  maternal  structures.  The  method 
o be  adopted  will  depend  much  on  the  situation  of  the  breech : if  it  be 
somewhat  low  in  the  pelvis,  our  finger  will  in  most  instances  be  sufficient 
or  our  purpose ; by  hooking  it  over  the  groin,  and  the  application  of  a 
ittle  traction,  we  may  probably  bring  the  breech  to  press  upon  the  peri- 
leum  ; we  shall  then  most  likely  find  that  uterine  action  is  increased  in 
iroportion  as  the  perineum  becomes  distended ; and  that  no  farther  ex- 
tractive aid  is  required.  But  should  the  breech  be  so  high  that  we  are 
inable  to  insinuate  our  finger  round  the  thigh,  so  as  to  give  us  the  requi- 
re command,  we  may,  by  another  very  simple  means,  produce  a most 
valuable  and  useful  purchase : the  extremity  of  a silk  or  cambric  handker- 
chief may  be  worked  over  the  groin,  without  any  great  difficulty:  by  draw- 
ng  down  the  end  of  which,  a loop  is  formed  round  the  foetal  limb,  and  a 
nost  powerful  hold  is  obtained.  If  the  handkerchief  be  used  carefully 
nd  tenderly,  it  is  preferable  to  an  iron  hook ; but  should  the  application  of 
he  handkerchief  be  difficult  or  impracticable,  we  possess  an  instrument, — 
nore  efficient,  perhaps,  but  more  dangerous, — in  the  blunt  hook, — to  be 
mployed  only  as  a last  resource.  If  the  breech  have  entered  in  any  de- 
cree into  the  cavity  of  the  pelvis,  we  can  generally  succeed  in  encompass- 
ng  one  or  other  limb  by  a small-sized  hook.  Having,  then,  warmed  and 
;reased  the  instrument,  we  carry  its  handle  up  towards  the  abdomen,  in- 
roduce  its  point  within  the  vagina,  and  insinuate  it  over  the  bend  of  one 
high,  directing  it  by  the  first  finger  of  the  left  hand,  previously  passed 
ound  the  groin ; gentle  traction  must  then  be  made  in  the  direction  to- 
vards  the  coccyx,  and  we  shall  most  probably  find  the  foetal  body  de- 
fend. Plate  XL1I.  fig.  123,  shows  the  blunt  hook,  applied  over  the  thigh, 
he  first  finger  of  the  left  hand  guarding  its  point.  In  making  use  of  the  • 
Purchase  we  thus  obtain,  we  must  not  lose  sight  of  the  delicacy  of  the 
hild’s  structures,  and  the  imperfectly  ossified  state  of  the  bones ; and  we 
aust  bear  vividly  in  our  mind  the  remembrance  of  the  grievous  injuries 
ve  may,  without  caution  inflict  upon  its  person. 


296 


PRETERNATURAL  LABOUR. 


In  the  cases  now  under  consideration,  as  well  as  those  of  impaction  of 
the  breech,  we  have  been  recommended  by  some  practitioners*  to  adapt 
the  forceps  over  each  ilium  of  the  child — if  the  os  uteri  be  dilated — and  to 
extract  by  a movement  similar  to  that  used  when  they  are  applied  upon 
the  head;f  there  are,  however,  numerous  objections  to  this  mode  of  pro- 
ceeding. The  instrument  not  being  made  for  the  breech,  but  for  a more 
globular  body,  does  not  fit  that  part,  and  is  liable  to  slip,  to  the  great 
hazard  of  the  mother’s  structures.  The  only  way,  indeed,  by  which  we 
can  cause  the  blades  to  keep  their  hold  at  all,  is  by  squeezing  the  handles 
firmly  together,  so  that  the  points  may  take  a deep  nip  upon  the  foetal 
body ; and  the  youngest  student  in  anatomy  would  at  once  call  to  memory 
important  organs  likely  to  suffer  severely  from  this  rude  pressure.  The 
foetal  pelvis  might  be  broken ; and  that  would  be  an  accident  of  no  trifling 
importance.  We  may  also  do  irreparable  injury  to  some  of  the  soft  parts. 
The  liver,  from  its  large  size  in  the  foetus,  occupying,  as  it  does,  the  chief 
part  of  the  abdomen,  with  its  edge  descending  nearly  to  the  pelvic  brim, 
is  much  exposed  to  be  bruised  or  ruptured ; and  this  injury  is  the  more 
likely  to  happen  in  consequence  of  its  high  vascularity,  and  the  tenderness 
of  its  substance : nor  are  the  intestines  altogether  secure  from  the  chance 
of  being  wounded.  For  such  reasons,  then,  I consider  the  forceps  inap- 
plicable to  cases  of  breech  presentation ; and,  if  assistance  be  required, 
would  infinitely  prefer  either  of  the  three  methods  above  recommended. 

Distortion  of  the  pelvis. — Supposing,  however,  that  the  protraction  is 
caused  by  a want  of  room  in  the  bony  pelvis,  and  that  the  diminution  of 
space  is  at  the  brim,  in  the  conjugate  diameter, — where,  indeed,  we  usually 
observe  it  to  exist, — it  is  evident  that  such  a case  must  be  difficult  in  propor- 
tion as  the  pelvis  is  contracted ; and  we  shall  sometimes,  as  in  head  pre- 
sentations, find  that  difficulty  almost  insurmountable. 

Our  first  duty,  under  such  a state  of  things,  is  to  detect  the  cause  of  de- 
lay ; and  we  can  have  little  difficulty  in  determining  this  point,  for  the 
uterus  would  most  likely  be  acting  sufficiently  strongly  to  propel  the  breec’ 
through  the  brim,  if  there  were  space  enough  to  admit  it ; and  we  cai 
positively  measure  the  dimensions  of  the  pelvis  as  easily  as  though  the 
head  presented,  and  by  the  same  means.  The  only  question  is  as  to  th« 
space  necessary  for  the  transmission  of  the  breech.  Now  this  part  of  the 
foetal  body  does  not  possess  a circumference  so  large  as  the  head,  and 
.being  softer,  it  is  more  compressible ; so  that  it  may  be  squeezed  througl 
a smaller  aperture  than  the  cranium,  while  wThole,  would  require : at  the 

* Hamilton,  Practical  Observations,  1840,  p.  298. 

t VVc  read  in  Baudelocque  (parag.  1251,  translation)  that  this  mode  of  delivery  was  first  ac- 
complished by  a practitioner  who  mistook  the  breech  for  the  head,  adapted  the  forceps,  and 
afterwards  boasted  of  his  novel  success. 


BREECH  PRESENTATIONS. 


297 


same  time,  however,  since  it  possesses  no  cavity  which  can  be  opened, 
and  no  contents  which  can  be  evacuated,  it  is  impossible  to  draw  it 
through  so  small  a pelvis  as  the  mutilated  and  collapsed  skull.  If,  indeed, 
the  pelvis  measure  but  two  inches  and  a half  from  pubes  to  sacrum,  I am 
persuaded  the  double  breech  may,  by  management,  be  made  to  pass,  and 
that  it  could  be  extracted  through  a considerably  less  space,  provided  the 
legs  were  first  brought  down. 

But,  even  if  we  succeed  with  the  breech,  a larger  space  is  required  for 
the  shoulders;  and  if  they  pass,  still  there  is  more  room  necessary  for  the 
passage  of  the  head,  so  that  we  have  difficulty  following  difficulty,  and 
each  of  them  greater  than  the  one  preceding.  This,  indeed,  is  just  the  re- 
verse of  what  happens  under  a head  presentation  ; for,  generally  speaking, 
when  the  head  is  born,  the  body  can  be  extracted  with  comparative  ease. 

Being,  then,  fully  satisfied  that  the  breech  presents ; having  learned  that 
the  pelvis  is  malformed  or  small,  the  woman  having  been  some  hours  in 
strong  labour ; perceiving  that  there  is  a chance  of  her  sinking  under  her 
continued  struggles,  unless  she  be  assisted, — we  are  fully  warranted  in 
offering  relief  by  the  means  I have  already  stated.  It  is  not,  indeed,  ne- 
cessary to  wait  until  the  os  uteri  is  entirely  dilated,  because  the  breech 
may  be  extracted  through  the  pelvic  brim  before  full  dilatation  has  taken 
place,  provided  the  organ  be  soft  and  distensible.  It  is  our  duty,  in  all 
instances,  to  endeavour  to  extract  the  child  without  injury  to  its  person; 
but  should  the  diminution  of  space  be  great,  we  can  scarcely  expect  that 
it  will  pass  alive;  because  if  it  be  at  the  full  time,  and  well  ossified,  we 
shall  most  likely  be  obliged  to  evacuate  its  brain  before  the  head  can  be 
born.  Notwithstanding  this  probability,  since  in  the  particular  case  under 
treatment  it  may  be  smaller  or  less  ossified  than  usual,  we  must  be  most 
careful  to  prevent  injuring  its  limbs,  by  the  efforts  we  make  for  its  libera- 
tion. 

A gentle  swaying  motion  from  side  to  side  will  facilitate  the  escape  of 
the  body,  after  the  passage  of  the  breech,  which  being  born,  one  shoulder 
must  be  turned  into  the  hollow  of  the  sacrum,  and  the  other  brought  under- 
neath the  pubes.  The  arms  must  be  extracted  in  the  manner  already 
pointed  out,  and  the  head  must  be  brought  to  the  pelvic  brim,  in  the  situa- 
tion most  favourable  for  its  exit;  namely,  with  the  face  to  one  ilium,  and 
the  occiput  to  the  other ; or  with  the  face  looking  towards  one  sacro-iliac 
symphysis,  and  the  occiput  behind  the  opposite  groin.  We  must  then 
pass  the  finger  of  one  hand  into  the  mouth,  and  depress  the  chin,  while  we 
make  traction  by  the  first  two  fingers  of  the  other,  fitted  like  a crutch 
across  the  shoulders ; taking  care  not  to  dislocate  the  neck  or  injure  the 
jaw.  By  this  means  we  shall  probably  enable  the  head  to  pass  the  brim  ; 
and  when  it  has  entered  the  pelvic  cavity,  we  may  turn  the  face  into  the 
38 


298 


PRETERNATURAL  LABOUR. 


hollow  of  the  sacrum,  and  we  shall  mostly  have  it  in  our  power  to  com- 
plete the  delivery  with  little  difficulty,  since  the  principal  impediment  will 
have  been  already  overcome.  (Plate  XLI.  fig.  122.) 

Wherever  there  exists  a diminution  of  space  at  the  superior  aperture  ol 
the  pelvis,  it  is  even  more  necessary  to  be  careful  that  the  face  is  turned 
to  the  iliac  fossa  while  the  head  is  passing  the  brim,  that  when  the  organ 
is  of  normal  size;  for  reasons  not  necessary  to  be  insisted  on. 

If,  then,  we  have  placed  the  head  in  this  most  favourable  situation,  and 
made  use  of  as  much  exertion  as  we  think  ourselves  warranted  in  doing, 
for  the  space  of  twenty  or  thirty  minutes,  without  the  expected  success, 
we  shall  be  compelled  to  diminish  its  bulk  for  the  purpose  of  accomplishing 
extraction  ; and  the  operation  is  not  much  more  difficult  than  if  the  head 
had  originally  presented. 

The  same  deadly  instruments  are  required  for  perfecting  this  intention. 
The  cranium  must  be  perforated,  and  the  brain  partially  evacuated  ; but 
we  do  not  feel  so  much  compunction  in  having  recourse  to  this  measure 
as  we  should  do  in  most  cases  where  the  head  presents,  because  the  child 
must  be  dead  before  the  operation  can  be  required.  No  person  would 
think  of  perforating  the  skull  before  some  considerable  efforts  had  been 
made  to  extract  it  entire ; and  under  those  efforts  the  chance — amounting 
almost  to  a certainty — is,  that  the  pressure  on  the  funis  would  have  beeii 
such  as  to  destroy  the  foetal  life.  On  some  occasions  I have  witnessed 
the  gradual  death  of  the  infant  from  this  cause,  while  J was  unable  tb 
prevent  it,  or  advance  succour;  and  in  others  I have  delayed  applying  the 
destructive  means  until  the  vital  spark  had  flown ; shrinking  from  being 
myself  the  instrument  of  death,  but  choosing  rather — however  sad  the 
alternative— to  wait  quietly  until  I was  assured  the  heart’s  last  pulse  had 
throbbed. 

Mode  of  performing  the  operation. — The  woman  lying  on  her  left  side  ; 
an  assistant  must,  by  drawing  down  the  body,  bring  the  child’s  hear 
down  as  low  as  possible,  and  turn  the  neck  upwards,  under  the  symphvsi 
pubis,  so  that  one  acromion  is  towards  the  mons  veneris , and  the  othe 
towards  the  fourchette.  An  unoccupied  space  at  the  back  part  of  the  pelvi 
is  thus  procured,  into  which  we  can  insinuate  two  or  three  fingers,  of  th 
left  hand  with  ease;  they  n^ust  be  carried  up  against  the  skull,  to  th 
projection  behind  that  ear  which  is  next  the  sacrum.  Along  these  tw- 
fingers  a perforator  must  be  passed ; and,  making  steady  pressur 
against  the  part,  with  a semi-rotatory  motion  we  introduce  its  point  with! 
the  skull  as  far  as  the  rests;  the  two  handles  of  the  instrument  must  the. 
be  separated  by  an  assistant,  the  rests  being  protected  by  our  own  fingero, 
in  the  way  that  I recommended  before,  Plate  XXXVI.  fig.  110,  and  a 
crucial  incision  made,  if  practicable.  Having  made  an  aperture  sulfi- 


BREECH  PRESENTATIONS. 


299 


ciently  large  to  admit  the  perforator  fully  within  the  cranium,  we  break 
down  the  brain  as  perfectly  as  possible,  and  commence  extraction.  We 
seldom  require  to  use  an  extracting  instrument,  since  the  means  of  traction 
is  afforded  by  the  body  of  the  foetus  itself ; but  if  it  should  be  requisite, 
we  can  fix  the  crotchet  on  the  inner  surface  of  the  bone,  and  a very  firm 
purchase  is  obtained,  because  of  the  strength  of  the  cranium  at  this  part. 
It  may  possibly  slip,  or  break  away  from  its  hold,  when  another  point  of 
resistance  must  be  sought  for ; and  while  making  these  efforts  we  must  be 
most  assiduous  in  guarding  the  extremity  of  the  instrument  by  our  finger, 
to  prevent  laceration  of  the  os  uteri  or  vagina.  If  possible,  an  extracting 
instrument  should  be  avoided ; but  if  any  be  required,  the  crotchet  or  blunt 
hook  appear  to  me  much  the  most  applicable. 

There  is  certainly  more  difficulty  in  perforating  the  skull  behind  the 
ear,  than  when  the  vertex  presents ; and  that  for  three  reasons.  In  the  first 
place,  the  vagina  being  partly  occupied  by  the  neck,  our  movements  are 
rather  impeded.  Secondly , the  bones,  at  the  base  of  the  skull  are  thicker, 
and  consequently  we  must  use  more  exertion  in  perforating  them.  And, 
thirdly , the  point  of  the  instrument  is  more  liable  to  slip  to  one  side — to 
run  up  between  the  bone  and  the  scalp,  and  not  to  enter  the  skull  at  all. 
Such  an  occurrence  is  easily  known  by  the  very  slight  resistance  offered 
to  the  passage  of  the  instrument  up  to  the  rests ; and  also  by  examining 
the  laceration  we  have  made  by  the  finger,  after  its  withdrawal.  If  we 
find  no  jagged  edge  of  bone,  it  is  merely  the  scalp  that  is  punctured,  and 
we  must  make  another  attempt,  by  turning  the  extremity  of  the  instru- 
ment a little  more  in  the  direction  of  the  centre  of  the  cavity  of  the  skull. 
Sometimes,  indeed,  the  perforator  will  slip  in  the  same  manner  between 
the  skull  and  the  scalp,  when  applied  to  the  vertex  under  a head  presenta- 
tion, and  may  produce  some  embarrassment ; but  this  mischance  is  not  so 
likely  to  occur  when  the  head  presents,  as  in  the  case  now  under  consi- 
deration, because  we  have  then  a better  opportunity  of  directing  the  point 
against  the  spot  most  dependent,  and  because  the  bones  at  the  upper  part 
of  the  cranium,  not  being  so  resistant,  yield  more  readily. 

If  Plate  VII.  figs.  23,  24,  and  Plate  VIII.  fig.  26,  be  consulted,  they 
Avill  immediately  show  that  it  wmuld  be  impossible  for  the  breech  to  pass 
through  them,  even  when  diminished  to  the  utmost  extent  it  is  capable  of, 
"-—by  the  legs  having  been  first  extracted, — and  compressed  into  as  small 
a space  as  the  semi-ossified  structures  will  allow.  Under  such  an  aggra- 
vated state  of  disproportion,  one  alternative  alone  is  offered  us, — that  of 
performing  the  Caesarean  section ; and  it  becomes  of  importance  to  deter- 
mine the  size  of  the  pelvis  under  which  w7e  are  warranted  in  having 
recourse  to  this  terrible  expedient.  It  appears  to  me  that  somewhat  more 


300 


PRETERNATURAL  LABOUR. 


room  would  be  required  for  the  transmission  of  the  body  and  shoulders,  j 
under  a breech  presentation,  than  when  the  head  rests  above  the  brim ; 
and,  provided  the  conjugate  diameter  measured  less  than  one  inch  and 
three  quarters,  I should  think  myself  justified  in  proposing  the  abdominal 
incision.  It  certainly  never  occurred  to  myself  to  meet  with  a case  in 
which  the  breech  would  not  pass  by  the  use  of  the  means  before  recom- 
mended : such  instances,  however,  are  far  from  impossible.  Even  should 
we  succeed,  after  much  exertion,  in  extracting  the  body  and  shoulders  of 
the  child  through  a pelvis  less  than  the  dimensions  I have  just  noticed, 
still  I apprehend  that  the  head,  in  this  position,  would  require  considerably 
more  space,  after  perforation  was  effected,  than  when  the  vertex  pre- 
sented ; and  on  this  account  also  I should  be  inclined  not  to  attempt  deli- 
very per  vias  naturales,  unless  there  existed  a clear  space  of  one  inch 
and  three  quarters,— at  least  if  there  were  indications  of  the  child  being 
alive. 

Pelvic  tumours. — Other  causes  than  distortion  of  the  pelvic  bones  may 
occasion  a want  of  the  necessary  space  for  the  passage  of  the  breech : 
thus,  tumours  may  have  formed  in  the  cavity,  such  as  I have  before  men- 
tioned— exostosis,  diseased  ovaries,  scirrhous  and  suppurating  glands, 
polypi,  and  some  others;  and  there  are  no  specific  rules  which  we  can 
apply  to  breech  presentations,  under  these  deviations  and  difficulties,  that 
are  not  applicable  also  to  cases  in  which  the  head  presents.  Our  indica- 
tions are  exactly  the  same : we  save  the  child  if  we  can,  but  not  at  the 
expense  either  of  the  mother's  life,  or  of  extensive,  and  perhaps  eventually 
fatal,  injuries  to  her  person. 

If  the  tumour  possess  distinct  fluctuation,  whether  it  be  a suppurating 
gland  or  enlarged  ovary,  it  should  be  punctured.  If  there  be  a polypus 
in  the  pelvis,  impeding  the  passage  of  the  child’s  breech,  trunk,  or  head, 
it  should  be  removed,  provided  that  can  be  done  without  much  danger  to 
the  mother ; but  if  the  tumour  be  hard  and  immoveable,  so  that  we  cannot 
lessen  its  bulk,  and  fear  to  dissect  it  away  from  its  attachments,  we  must 
act  upon  the  common  principles,  wait  for  some  time,  in  the  hope  that, 
nature  may  overcome  the  impediment,  and  if  she  fail,  traction  must 
made  with  the  finger  or  blunt  hook  surrounding  the  groin ; or  the  Caisa*? 
rean  section  must  be  resorted  to,  according  to  the  available  space  which 
the  pelvis  possesses. 

Rigidity  of  the  os  uteri , vagina , and  perineum , singly  or  combined, 
may  occasion  difficulty,  as  noticed  under  the  head  of  lingering  labour. 

Under  this  complication,  the  os  uteri  may  probably  be  relaxed  by 
bleeding,  by  enemata,  by  the  injection  of  warm  oil  or  mucilaginous  fluids 
into  the  vagina,  and  we  may  possibly  deem  it  necessary  to  exhibit  opium ; 
the  vagina  and  perineum  may  also  be  softened  perhaps  by  artificial  lubri- 


TRANSVERSE  PRESENTATIONS. 


301 


cation  and  external  fomentations.  Failing  in  these  means,  delivery  must 
be  resorted  to,  by  measures  already  sufficiently  explained. 

Head  left  in  utero. — In  the  ages  of  rude  surgery*  it  has  not  unfre- 
quently  occurred,  that  the  head  has  been  separated  at  the  neck  by  violent 
and  ill-directed  efforts,  and  left  in  utero  after  the  extraction  of  the  rest  of 
the  body ; but  to  meet  with  such  a case  is  now  rare.  The  only  instance 
in  which  this  accident  came  under  my  own  treatment,  happened  in  the 
practice  of  a midwife  attached  to  a charity  of  which  I have  the  charge. 
The  child  was  putrid,  and  she  had  been  attempting  to  extract  it  without 
reference  to  the  propriety  of  its  position.  When  I arrived,  I found  the  chin 
hitched  upon  the  sacral  promontory,  the  vertebras  entirely  separated,  and 
the  cranium  attached  to  the  body  by  a very  small  portion  of  integument 
which  gave  way  completely  on  the  least  handling.  There  was  a tumour 
in  the  pelvis,  that  possessed  the  characteristic  of  an  enlarged  ovary. 
Not  desirous  of  encountering  these  difficulties  alone,  I requested  my 
father’s  assistance,  who  promptly  attended.  Having  introduced  his 
hand  into  the  uterus,  he  changed  the  position  of  the  head,  so  that 
the  crown  came  to  the  pelvic  brim,  and  perforated  it  at  the  sagittal 
suture,  while  I steadied  the  uterine  tumour  externally.  We  had  then 
little  trouble  in  extraction ; and  this  method  appears  to  me  the  most  likely 
to  succeed  of  any  which  has  been  practised  ; but  under  such  anomalous 
cases  no  rule  can  be  laid  down  for  universal,  and  scarcely  for  general 
guidance. 


2d.  TRANSVERSE  PRESENTATIONS. 


The  second  order  of  preternatural  cases  embraces  all  those  in  which 
any  other  part  of  the  fcetal  body  presents,  than  the  head,  breech,  or  infe- 
rior extremities.  When  the  foetus  lies  transversely,  the  long  diameter 
formed  by  its  doubled  body  being  across  the  uterus  from  side  to  side,  the 
familiar  term  cross-birth  is  peculiarly  applicable;  and  to  this  variety  of 
preternatural  cases  it  should,  in  strict  propriety,  be  limited. 

I have  already  stated  it  as  my  opinion,  that  there  is  no  part  of  the  child’s 
4ody  which  may  not  offer  itself  as  a presentation  under  labour.  It  will 
therefore  necessarily  follow,  that  when  situated  transversely,  the  head  may 

* See  yEtius,  tetrab.  iv.  sermo  iv.  cap.  22 ; also  Pare,  book  24,  chap.  26.  Experience  has 
given  me  reason  to  believe  that  a head  may  be  extracted  entire,  when  the  body  is  born,  through 
a smaller  pelvis  than  would  admit  of  its  passage  under  a vertex  presentation,  if  the  neck,  is 
sufficiently  strong  to  afford  the  means  of  moderate  traction,  and  a finger  can  be  satisfactorily 
introduced  into  the  mouth. 


302 


PRETERNATURAL  LABOUR. 


lie  upon  the  right  or  left  ilium,  with  the  face  directed  either  forwards  or 
backwards,  so  that  either  the  right  or  left  side,  the  back,  chest,  or  abdo- 
men, may  be  placed  downwards. 

It  is  of  the  greatest  importance  that  we  should  be  able  to  discriminate 
in  practice  between  the  first  and  second  orders  of  preternatural  presenta- 
tions, because — as  already  shown — those  which  are  embraced  within  the 
first  are,  generally  speaking,  terminated  by  the  efforts  of  nature  alone,  or 
with  very  little  artificial  assistance ; while,  in  those  characterizing  the 
second  order,  the  very  reverse  obtains ; — the  child  is  so  placed  that  Nature 
unaided  can  scarcely  ever  effect  her  object;  and  an  operation  always 
attended  with  pain,  difficulty,  and  danger,  is  requisite  before  delivery  can 
be  accomplished.  This  operation,  if  undertaken  during  the  first  stage  of 
labour,  is  comparatively  easy ; but,  if  delayed  until  the  process  is  much 
advanced,  it  becomes  one  of  the  most  difficult  in  surgery  ; and,  cceteris 
paribus , the  danger  attendant  upon  it  is  in  proportion  to  the  difficulty.  It 
would  be  superfluous,  therefore,  to  insist  on  the  necessity  of  early  forming 
a correct  diagnosis.* 

There  are  no  symptoms  manifested  previously  to  the  commencement  of 
labour,  by  which  we  are  able  to  determine  that  the  child  lies  transversely 
in  utero.  It  has  been  said  that  if  the  uterus  in  its  general  figure,  be 
broader  than  it  is  long,  we  may  suspect  a transverse  presentation  under 
labour : this,  however,  is  by  no  means  universally  the  case ; is  it  but  a 
vague  supposition  at  the  best,  and  no  reliance  can  be  placed  on  it : for 
the  greater  breadth  of  the  uterus  may  depend  on  its  containing  twins  ; and 
although  they  both  may  be  lying  either  with  the  head  or  breech  down- 
wards, it  is  evident  that  the  organ  must  occupy  more  space  laterally  than 
if  there  were  but  one  child  lying  in  the  natural  position.  An  increased 
quantity  of  liquor  amnii  may  also  influence  the  shape  of  the  gravid  womb; 
and  sometimes  the  uterine  fibres  are  not  developed  with  their  accustomed 
regularity,  but  some,  more  rigid  than  the  others,  refuse  to  yield  in  due 
proportion,  and  thus  occasion  an  unusual  form.  We  can,  therefore,  by 
no  means  rely  for  a diagnostic  mark  on  the  external  figure,  as  detected  i 
by  the  application  of  the  hand. 

JVor  are  there  any  causes  evident  to  which  we  can  assign  this  peculiar 
presentation  of  the  foetus.  I have  already  mentioned  that  particular  pos* 

* As  in  breech  presentations,  so  with  regard  to  transverse  cases  the  proportion  to  natural 
births  has  been  variously  estimated.  In  the  Maternite  at  Paris,  out  of  10,742  children  born 
between  the  first  of  June  1829,  and  the  first  of  June  1833,  there  were  fifty-nine  by  “the 
trunk,”  about  one  in  every  182  cases.  (Dubois,  Mem.  de  PAcademie  Roy  ale,  tom.  iii.  p.  450, 
1833.)  Collins  (Op.  Cit.,  p.  73)  gives  us  an  average  of  one  in  nearly  416;  the  calculation 
being  taking  from  16,654  births,  • In  the  Royal  Maternity  Charity  in  this  city,  out  of  48,557 
births,  of  which  on  this  subject  I have  an  accurate  register,  the  proportion  of  transverse  cases 
is  one  in  nearly  every  326  cases,  including  twins  and  premature  children. 


TRANSVERSE  PRESENTATIONS. 


303 


tures  of  the  mother’s  body  were  supposed  to  regulate  in  some  degree  the 
position  of  the  child  in  utero : but  this  observation  is  proved  to  be  as 
incorrect  in  regard  to  shoulder  presentations  as  it  is  to  breech.* 

Transverse  presentations  are  by  no  means  comparatively  more  frequent 
among  the  poor  than  those  in  affluent  circumstances : but  some  women 
seem  to  be  naturally  predisposed  to  this  irregularity.  Thus  a patient, 
whom  I attended  in  all  her  labours,  out  of  five  children  which  she  has 
borne,  has  been  the  subject  of  four  transverse  presentations : her  pelvis  is 
slightly  distorted  at  the  brim.  And  another  woman,  now  dead,  who 
always,  under  pregnancy,  became  a patient  of  the  Royal  Maternity 
Charity,  in  twelve  labours  suffered  seven  shoulder  presentations.  I deli- 
vered her  myself  five  times  under  these  difficulties,  and  my  father  twice. 
This  person  also  possessed  a contracted  pelvis. 

Suspicious  symptoms. — It  is  then  only  after  labour  has  commenced,  and 
when,  indeed,  it  has  made  some  progress,  that  we  can  positively  detect  a 
transverse  presentation.  We  may  suspect  an  irregular  position,  if  the  os 
uteri,  although  flaccid,  opens  slowly — if  the  membranes  protrude  into  the 
vagina  rather  in  the  form  of  the  finger  of  a glove  than  the  round  end  of 
an  egg — and  if  we  cannot  feel  any  part  of  the  child,  even  when  the  finger 
is  carried  up  to  its  full  extent  within  the  vagina ; for  it  will  be  easily 
understood,  that  when  the  shoulder  presents,  the  foetus  cannot  descend 
into  the  pelvis  in  the  same  way  as  when  the  head  or  breech  offers  at  the 
brim,  being  supported  by,  and  resting  on,  the  alae  of  the  ilia. 

We  may  also  suspect  that  the  child  is  lying  transversely,  if,  when  the 
membranes  have  ruptured,  the  uterus  ceases  to  act  for  some  hours ; for  it 
often  happens  that  although  the  pains  were  frequent  and  powerful  before 
the  membranes  rupture,  they  cease  entirely  for  a considerable  time, 
directly  the  first  stage  is  completed ; and  we  presume  that  this  is  owing 
to  the  os  uteri  having  lost  the  stimulus  previously  afforded  it  by  the  aque- 
ous cyst,  while  it  remained  whole ; for  as  the  foetal  body  is,  as  it  were. 


* Mr.  Barlow’s  idea,  that  preternatural  presentations  are  more  frequent  under  distorted  than 
well-formed  pelves,  has  already  been  noticed,  page  272 ; and  Denman  (chap.  xiv.  section  8) 
incidentally  remarks,  “ Having  been  called  to  women  at  the  beginning  of  labour,  and  finding 
by  an  examination  that  the  head  of  the  child  presented,  I have  left  them  for  several  hours  till 
the  first  changes  were  naturally  made.  When  I have  examined  them  on  my  return,  I have 
found  the  arm  of  the  child  presenting,  the  head  being  departed  out  of  my  reach.  I do  not 
know  that  any  practical  advantage  is  to  obtained  by  a knowledge  of  these  cases ; but  it  is 
remarkable,  that  the  accident  has  always  happened  to  women  who  were  deformed.  Such 
cases  however  should  be  recorded,  and  it  is  possible  that  some  time  or  other  the  knowledge 
of  them  may  be  of  use.  It  may  lead  to  an  explanation  of  one  cause  at  least  of  preternatural 
labours.”  One  exactly  similar  instance  has  happened  to  myself;  and  other  practitioners  must 
probably  also  have  met  with  such  ; but  as  yet  no  useful  result  has  originated  from  Denman’s 
observation. 


304 


PRETERNATURAL  LABOUR. 


suspended  by  the  sides  of  the  maternal  pelvis,  the  presenting  part  cannot 
immediately  subside  to  the  mouth  of  the  womb,  as  occurs  when  either  the 
head  or  breech  is  protruded  first.  But  we  can  only  'positively  detect  a trans- 
verse presentation,  by  distinguishing  the  different  parts  of  the  child,  which 
indicate  to  us  the  mode  in  which  it  lies. 

Progress  of  the  labour. — Labour,  then,  would  most  likely  at  first  com- 
mence less  actively  than  under  a head  presentation ; the  uterus  would  be- 
come somewhat  diminished  in  bulk  before  the  dilating  process  commenced; 
but,  for  the  reasons  I have  assigned,  it  would  not  so  fully  descend  into 
the  pelvis  as  when  the  head  presents.  At  first  the  pains  would  be  short 
and  infrequent ; they  would  then  become  more  powerful ; the  membranes 
would  burst;  and  after  their  rupture,  the  uterus  would  probably  remain 
an  indefinite  time  inactive.  On  the  resumption  of  its  powers,  however, 
the  presenting  part  would  be  more  or  less  forced  down  into  the  pelvis;  and 
in  time,  provided  the  case  were  left  entirely  to  the  natural  efforts, — no 
artificial  assistance  of  any  kind  being  rendered, — one  of  three  things  must 
happen : either  the  uterus,  by  its  own  inordinate  action,  must  rupture  its 
own  structure — an  accident  which  is  almost  invariably  fatal ; or  by  a con- 
tinuance of  its  strong  exertions  it  must  wear  itself  out,  and  gradually 
cease  to  act,  which  state  will  be  accompanied  by  exhaustion,  and  death 
will  sooner  or  later  occur  ; or,  thirdly,  the  child’s  body  will  be  squeezed ! 
into  a smaller  compass — will  be  propelled  through  the  brim  into  the  cavity 
of  the  pelvis,  and  will  eventually  pass  double : for  I can  scarcely  believe « 
it  possible  that  the  woman  could  survive  the  entire  dissolution  of  the  foetal 
body  by  putrefaction,  the  separation  of  its  limbs  and  other  component  parts, 
and  their  evacuation  in  a disjointed  state.  The  doubled  expulsion,  or,  as 
it  has  been  called  by  Denman,  the  “ spontaneous  evolution,”  has,  indeed, 
been  occasionally  observed,  but  it  is  very  rare.  It  is  certainly  not  to  be 
expected,  and  scarcely  can  be  hoped  for  if  the  term  of  gestation  be  com- 1 
pleted.  Provided,  indeed,  the  woman  have  not  exceeded  six  and  a half, 
or  seven  months,  since  the  child  is  then  comparatively  so  small,  we  may ; 
with  some  confidence  look  for  it ; but  beyond  that  period  we  must  be  pre- 
pared to  terminate  the  labour  by  art. 

Marks  of  a transverse  presentation. — As  with  regard  to  the  breech,  so 
also  in  every  variety  of  transverse  presentations,  there  are  some  marks 
both  negative  and  positive,  which  assure  us  of  the  particular  part  that 
offers  at  the  pelvic  brim ; and  first  we  will  give  our  attention  to  that  which 
is  the  most  frequent  of  all — the 

Shoulder. — This  part  of  the  child’s  person  is  not  so  large  in  bulk,  nor 
so  hard  and  bony,  as  the  head ; and  it  has  neither  the  general  figure  of  the 
head  nor  its  sutures.  Again,  it  is  not  so  large  in  its  rotundity  as  one  of 
the  nates,  nor  is  it  so  fleshy ; we  cannot  feel  the  anus,  nor  the  parts  of 


Pi.XLm 


Fy.  MS. 


sSvzclc&v'j-  FifS 


b-.E 

.iNfVERSVi  »'  Of,  ILLINOIS 

• ~-Cm*  . 

■ ' h » ■ V- 


•V  *4- 


TRANSVERSE  PRESENTATIONS. 


305 


generation.  There  is  but  little  chance  of  our  confounding  the  shoulder  with 
the  cranium ; but  the  diagnostic  marks  between  it  and  the  breech  are  not 
so  easily  made  out ; there  is  a degree  of  similarity  to  the  touch  between 
the  top  of  the  shoulder  and  one  of  the  nates,  which  it  is  not  always 
easy  to  particularize.  The  positive  marks  are — the  pointed  acromion, 
most  dependent, — being  able  to  feel  the  spine  of  the  scapula  posteriorly, 
and  the  clavicle,  and  perhaps  the  ribs  anteriorly, — being  able  to  get  the 
finger  within  the  axilla,  and  not  encountering  any  structures  similar  to 
the  anus  or  genitals.  If  we  possess  the  advantage  of  discovering  all  these 
marks,  we  can  never  be  disappointed  in  distinguishing  that  the  presenting 
part  is  the  shoulder.  Plate  XLIII.  fig.  124  shows  the  left  shoulder  pre- 
senting at  the  brim  of  the  pelvis,  with  the  face  towards  the  spine,  the  mem- 
branes being  still  unbroken. 

Elbow. — It  sometimes  happens  that  the  child  presents  still  more  trans- 
versely, and  the  elbow  comes  down  doubled  into  the  pelvis,  offering 
itself  in  the  vagina.  Immediately  that  the  elbow  meets  the  finger,  we  can 
be  positive  that  a limb  presents ; we  may  easily  know  that  it  cannot  be  the 
head — that  it  cannot  be  the  breech  ; but  it  must  be  either  the  superior  or 
inferior  extremity.  The  foetus,  then,  may  be  placed  across  the  pelvis,  in 
that  situation  which  requires  the  performance  of  an  operation,  or  it  may 
be  so  situated  that  Nature,  unaided,  may  be  able  to  accomplish  delivery; 
so  that  it  is  a matter  of  the  greatest  consequence  to  determine  accurately 
which  limb  it  may  be.  Of  all  the  points  of  the  body,  it  is  most  difficult 
to  discriminate  between  an  elbow  and  a knee.  In  the  knee,  however,  we 
have  the  rounded  patella,  with  its  flat  surface,  which  is  more  or  less 
moveable  on  the  condyles  of  the  thigh-bone.  On  the  contrary,  in  the 
elbow  we  observe  the  pointed  olecranon  sharper  than  the  patella ; we  look 
in  vain  for  the  smooth  flat  surface  which  the  knee  presents,  and  we  can 
by  no  means  move  it  from  side  to  side.  This  last  distinctive  mark,  how- 
ever, of  the  presence  of  the  knee,  should  not  have  much  stress  laid  upon 
it,  as,  in  this  respect,  we  are  likely  to  be  deceived ; for  when  the  leg  is 
turned  back  on  the  thigh,  the  patella  is  so  fixed,  in  consequence  of  the 
extension  of  the  rectus  femoris,  that  its  mobility  is  considerably  impeded. 
Yet,  if  the  other  marks  are  borne  in  mind,  we  cannot  well  be  deceived. 
Should  any  doubt  still  exist,  let  us  not  lull  ourselves  into  dangerous  apathy 
by  calculating  the  many  chances  which  there  are  in  favour  of  its  being  a 
knee  rather  than  an  elbow  presentation ; but  let  us  institute  a more  careful 
sxamination.  If  no  part  of  the  child’s  body  except  the  presenting  limb  is 
to  be  felt— provided  the  membranes  are  broken — it  would  be  right  to  bring 
•he  folded  extremity  fully  down,— avoiding,  however , all  traction,— so  that 
we  may  be  able  to  ascertain  whether  it  be  an  arm  or  a leg ; for  even  should 
he  shoulder  or  side  be  occupying  the  brim,  this  proceeding  would  add  no 
39 


306 


PRETERNATURAL  LABOUR. 


difficulty  to,  and  not  in  the  least  embarrass  us  in,  the  subsequent  operation 
of  turning. 

Hand . — It  is  not  often  that  the  hand  presents  alone,  so  that  we  are  una- 
ble to  feel  any  other  part  of  the  child’s  body  : should  that,  however,  be  the 
case,  it  would  be  known  from  a foot,  (and  that  is  the  only  part  with  which 
it  can  possibly  be  confounded,)  by  negative  as  well  as  positive  signs — by 
there  being  no  rounded  instep — no  prominent  heel;  by  the  digits  not  all 
being  in  one  line.  The  positive  signs  are  the  flattened  palm,  the  fingers 
being  longer  than  the  toes,  and  themselves  not  all  of  the  same  length,  and 
the  thumb  forming  an  antagonist  power  to  the  other  four.  But  the  being 
able  to  feel  the  hand  does  not  necessarily  imply  that  the  child  lies  in  a trans- 
verse position ; for  it  is  by  no  means  unusual  for  this  member  to  be  placed 
upon  the  ear,  or  by  the  side  of  the  breech,  and  to  prolapse  before  either 
of  those  parts,  as  soon  as  the  membranes  break;  which  cases,  as  will  be  here- 
after proved,  require  little  artificial  interference.  It  becomes  our  duty, 
then,  as  soon  as  a hand  is  detected,  to  examine  most  minutely,  for  the 
purpose  of  ascertaining  whether  the  head,  breech,  or  shoulder,  be  at  the 
brim ; and  to  act  according  to  the  information  we  then  obtain. 

Side. — The  side  of  the  child  may  present,  and  here  also  we  have  some 
negative  as  well  as  positive  marks  to  guide  us.  The  side  possesses  neither 
the  roundness  nor  the  firmness  of  the  head,  nor  any  sutures  or  fontanelles; 
neither  is  there  the  double  rotundity  nor  the  soft,  fleshy  feel  of  the  breech: 
we  cannot  distinguish  the  parts  of  generation  nor  the  anus — we  can  feel 
no  part  of  the  child  except  the  ribs,  and,  it  may  be,  the  arm  also.  The 
side  may  be  principally  distinguished  by  the  spaces  between  the  ribs ; 
and  if  two  of  these  can  be  clearly  traced,  there  can  exist  no  doubt  as  to 
the  presentation.  The  head  is  the  only  part  of  the  body  for  which  the 
side  is  likety  to  be  mistaken ; and  I have  actually  known  this  mistake 
occur.  If  we  could  only  feel  two  ribs  and  one  intercostal  space,  it  might 
be  possible  for  us  to  be  deceived;  we  might  suppose  the  margin  of  the 
ribs  to  be  the  edges  of  the  parietal  bones,  and  the  space  itself  the  sagittal 
suture.  But,  if  there  be  any  doubt  in  regard  to  the  presentation,  it  is  bet- 
ter to  introduce  two  fingers  of  the  left  hand  fully  up  to  the  pelvic  brim, 
rather  than  allow  hour  after  hour  to  elapse  in  do.ubt  on  so  material  a 
question. 

Back. — A child  may  present  with  its  back,  Plate  XLIII.  fig.  125, 
although  this  is  a very  uncommon  position  for  it  to  lie  in.  Three  or  four 
of  the  spines  of  the  vertebra)  can  be  felt  by  the  fingers ; and  we  can  also 
detect  the  origins  of  the  ribs,  even  before  the  os  uteri  is  completely  dilated. 
When  the  back  presents,  it  is  of  no  consequence  whether  the  part  directly 
over  the  os  uteri  be  near  the  shoulder  or  the  breech, — whether  we  feel  the 
lumbar  or  the  dorsal  vertebra);  the  same  thing  is  required  to  be  done— the 


OPERATION  OF  TURNING. 


307 


hand  must  be  introduced  into  the  uterus,  and  the  breech  or  the  legs  must 
be  brought  down. 

Sternum . — The  chest  may  present, — any  point  of  the  sternum  meeting 
the  finger.  There  would  be  difficulty  in  detecting  this  presentation  by  the 
first  finger  of  the  right  hand ; but  by  introducing  two  fingers,  or  more,  of 
the  left  hand,  we  shall  feel  the  sternal  bones,  the  continuance  of  the  bony 
plane,  the  ribs, — or  rather  the  cartilages,  at  their  origin  from  the  sternum, 
— and  the  intercostal  spaces.  This  is  perhaps  a rarer  presentation  than 
any  of  those  previously  treated  of. 

Abdomen* — The  rarest  presentation,  perhaps,  of  all,  is  the  abdominal, 
Plate  XLIV.  fig.  126.  Out  of  nearly  one  hundred  and  fifty  transverse 
presentations  in  which  I have  operated,  I have  only  met  with  this  pecu- 
liar position  once.  If  the  case  were  allowed  to  proceed  without  inter- 
ference, the  abdomen  would  be  squeezed  somewhat  through  the  brim  of 
the  pelvis  after  the  membranes  break*  There  can  scarcely  be  a chance 
of  mistaking  this  presentation.  We  shall  feel  the  large,  soft  abdomen, 
possessing  no  osseous  formation ; we  shall  perhaps  be  able  to  distinguish 
the  ensiform  cartilage;  but  a more  positive  mark  is  the  insertion  of  the 
funis  nmbilicalis.  Whenever  we  can  feel  the  commencement  of  the  cord 
by  the  finger,  there  exists  a belly  presentation,  most  undoubtedly.  It  must 
not,  however,  be  supposed  that  all  cases  in  which  a fold  of  the  funis  comes 
down  into  the  vagina  must  turn  out  presentations  of  the  abdomen,  because 
the  cord  frequently  prolapses  when  other  parts  of  the'child  are  at  the  brim. 
Plate  XXXIX.  fig.  118,  PI.  XLIV.  fig.  127,  and  PI.  L.  fig.  138. 

We  sometimes  meet  with  more  complicated  presentations,  such  as  both 
the  hands  and  feet  together,  or  one  of  each  different  limb.  Plate  XLIX. 
fig.  127,  delineates  a case  in  which  a hand,  the  feet,  and  the  funis  offered 
themselves  at  the  os  uteri.  In  such  a case  the  evident  means  of  relief 
would  be  to  bring  down  the  feet,  and  cause  the  breech  to  occupy  the 
pelvic  cavity.  The  feet,  a hand,  and  the  breech,  are  not  very  unfrequently 
detected  together  at  the  pelvic  brim ; and  I have  known  some  few  instances 
in  which  the  head,  a foot,  and  a hand,  were  all  presenting  at  the  same 
time.  If  it  were  practicable  under  such  a complication,  it  would  be  most 
advisable  to  push  the  hand  and  foot  above  jJ^e  brim — as  will  be  hereafter 
more  particularly  advised — and  allow  the  head  to  come  down  alone ; if 
not  to  turn  the  child  by  traction  at  the  foot,  and  bring  down  the  breech. 

Operation  of  turning. — Having  determined  that  the  case  under  a trans- 
verse presentation  is  not  to  be  left  to  nature— that  it  is  more  likely  that 
the  uterus  will  rupture,  or  that  the  patient  will  die  exhausted,  than  that 
the  child  will  pass  double— we  must  make  up  our  minds  to  change  its 
position  by  operation.  First,  then,  we  will  inquire  in  what  that  operation 


308 


TRANSVERSE  PRESENTATIONS. 

consists ; and,  secondly,  what  period  of  the  labour  we  shall  select  for  its 
performance. 

Modes  in  which  the  operation  of  turning  may  he  performed.— Three  diffe- 
rent modes  have  been  recommended,  and  they  all,  perhaps,  enjoy  their  pe- 
culiar advantages. 

The  first  is,  that  we  should  raise  the  presenting  part,  introduce  the  hand 
into  the  uterus,  seize  hold  of  the  head,  bring  it  to  the  brim  of  the  pelvis 
and  convert  the  case  into  a natural  presentation.  The  second  advice  is, 
that  we  should  introduce  the  hand  into  the  uterus,  run  it  along  the  abdo- 
men of  the  child,  take  hold  of  the  breech  firmly,  grasp  it  with  the  fingers, 
bring  it  to  the  pelvic  brim,  and  make  it  a breech  case.  And,  lastly,  it  is 
recommended  to  introduce  the  hand  as  high  as  the  fundus  uteri,  running 
it  along  the  body  of  the  child,  search  for  the  feet,  and,  bringing  down  one 
or  both,  make  the  child  perform  a complete  evolution,  and  extract  it  foot- 
ling.* 

Of  these  three  modes,  that  of  raising  the  shoulder  and  bringing  down 
the  head  would  be  the  safest  to  the  child,  because  there  would  then  be 
little  chance  of  pressure  on  the  funis  umbilicalis;  and  it  is  that  pressure 
which  usually  destroys  the  foetus,  when  extracted  by  the  breech  or  feet; 
— but  although  safest  for  the  child  it  is  the  most  dangerous  to  the  mother, 
as  well  as  the  most  difficult  to  the  operator;  and  the  danger,  as  might  be 
expected,  is  in  proportion  to  the  difficulty.  The  form,  size,  and  slippery 
nature  of  the  cranium,  all  combine  to  produce  this  difficulty.  Even 
although  the  shoulder  might  be  raised  from  the  brim,  and  pushed  entirely 
out  of  the  way,  it  is  no  easy  matter  to  grasp  the  head,  so  as  to  bring  the 
vertex  over  the  centre  of  the  superior  aperture ; and  in  these  attempts, 
which  will  most  likely  require  to  be  repeated,  both  the  uterus  and  vagina 
would  be  seriously  endangered.  From  the  danger  and  difficulty  accom- 
panying this  operation,  it  is  now,  I believe,  entirely  abandoned  in  England 
as  a means  of  delivery  under  transverse  presentations,  although  recom- 

* The  ancients  were  folly  impressed  with  the  danger  of  transverse  presentations;  and  in 
the  works  of  iEtius,  who  was  a compiler  from  previous  authors,  hints  may  be  found  relative? 
to  bringing  down  the  feet  by  turning,  under  such  an  unfortunate  situation.  (Tetrab.  iv.  sermo 
iv.  cap.  22.)  The  operation,  however,  was  not  generally  adopted  till  the  time  of  Pare,  to 
whom,  although  he  be  not  the  first  sliggester  of  this  great  practical  improvement,  is  justly 
due  the  honour  of  having  satisfactorily  proved  its  safely  and  utility,  and  enforced  its  adoption, 
both  by  his  precepts  and  example.  (Book  24,  chap.  26.)  Before  Pare’s  time,— the  middle  of 
the  sixteenth  century, — there  seem  to  have  been  insinuated  no  precise  rules  for  the  manage- 
ment of  this  order  of  preternatural  cases ; It  was  the  almost  invariable  practice  to  endeavour 
to  bring  the  head  over  the  pelvic  brim,  but,  failing  in  that  attempt,  most  writers  directed  that 
the  child  should  be  extracted  in  whatever  manner  was  most  practicable.  In  Celsus,  indeed* 
we  find  it  recommended,  that  if  the  foetus  when  transverse  cannot  he  brought  into  a proper 
direction — that  is,  with  the  head  or  feet  over  the  pelvic  brim — a hook  should  be  fixed  in  the 
axilla,  and  traction  gradually  made  by  it;  and  that  the  neck  thus  doubled  should  be  divided. 
(Lib.  vii.  cap.  29.)  This  advice  indeed  is  given  as  applicable  only  to  a dead  child. 


OPERATION  OF  TURNING. 


309 


ended  by  Dubois,  as  applicable  to  some  few  cases.  Thus  of  the  fifty- 
ne  cases  of  presentation  of  the  trunk  just  adverted  to.  that  happened  in 
e Maternite  at  Paris,  he  states  that  two  were  terminated  by  bringing  the 
ad  to  the  pelvic  brim. 

Delivery  by  the  breech  offers  an  expedient  second  in  degree  safe  to  the 
iild. ; for,  as  already  mentioned,  when  the  legs  and  feet  lie  up  against  the 
ild’s  body,  the  funis  umbilicalis  is,  to  a certain  extent,  protected  from 
essure,  and  the  passages  having  been  considerably  distended  by  the 
msit  of  the  breech,  are  rendered  in  a fitter  state  for  the  easy  escape  of 
3 shoulders  and  the  head,  than  when  the  feet  are  first  brought  down, 
it  this  mode  of  acting  is  also  both  difficult  and  somewhat  dangerous,  and 
at  from  the  same  causes  as  embarrass  the  operator  in  the  attempt  to  bring 
wn  the  head.  We  are  not  able  to  encompass  the  breech  readily; — we 
nnot  easily  grasp  it,  so  as  to  bring  it  over  the  pelvic  brim,  in  consequence 
its  bulk  and  form. 

The  third  means  is  by  far  the  most  dangerous  to  the  child,  but  by  far, 
so,  the  safest  to  the  mother — that  of  grasping  one  or  both  feet,  bringing 
3 breech,  through  the  hold  they  afford,  into  the  pelvis,  and  extracting 
3 foetus  by  their  agency.  This  is  the  mode  of  delivery  now  almost  uni- 
rsally  adopted  both  in  this  country  and  on  the  continent,  and  which  I 
>uld  strongly  recommend  in  preference  to  either  of  the  others,  in  all 
ses  where  there  is  a necessity  for  turning  the  child. 

Period  when  the  operation  should  he  performed. — The  time  most  favour- 
le  for  changing  the  position  of  the  child  is  when  the  os  uteri,  vagina, 
d external  parts,  are  perfectly  relaxed,  while  the  membranous  cyst 
nains  still  entire.  The  operation,  then,  should  be  delayed  as  long  as  is 
nsistent  with  the  integrity  of  the  membranes,  and  the  preservation  of  the 
uor  amnii  within  the  uterine  cavity ; for  the  presence  of  the  water  allows 
3 easy  introduction  of  the  hand  completely  within  the  womb,  and  per- 
ts  the  child  to  be  changed,  by  means  of  the  feet,  in  any  direction  which 
desirable.  If,  then,  we  have  the  conduct  of  the  case  from  the  commence- 
3nt,  we  should  operate  before  the  membranes  break. 

But  again,  we  cannot— and  it  would  be  idle  to  suppose  that  we  could— 
ss  our  hand  into  the  uterus  before  relaxation  of  the  vagina  and  dilata- 
n of  the  os  uteri  have  proceeded  to  some  extent.  We  could  not  expect 
be  able  to  effect  our  object,  if  the  os  uteri  were  not  opened  beyond  the 
e of  a sixpence  or  a shilling,  unless,  indeed,  it  were  much  softer  than 
usual  under  this  slight  degree  of  dilatation ; but  when  it  has  acquired  the 
imeter  of  half  a crown,  or  a crown,  it  will  generally  suffer  itself  to  be 
ated  to  such  an  extent  as  will  admit  the  hand,  without  injury  to  its 
ucture. 

Since,  then,  it  may  be  laid  down  as  a maxim  that  it  is  highly  desirable. 


310 


TRANSVERSE  PRESENTATIONS. 


under  a transverse  presentation,  to  change  the  position  of  the  child  pre 
viously  to  the  rupture  of  the  membranes,  but  that  it  is  almost  impossible 
to  accomplish  this  object  before  the  os  uteri  has  acquired  a certain  diame- 
ter— since,  also,  there  is  great  danger  of  the  membranes  breaking  as  soor 
as  the  bag  occupies  the  vagina,  so  as  to  press  at  all  upon  the  externa 
parts— it  becomes  of  importance  that  we  should  lay  down  some  rule  foi 
our  guidance  in  these  cases,  not  perhaps  universally  to  be  followed,  but  tc 
be  classed  among  our  general  precepts ; and  the  following  seems  the  mosl 
applicable. 

As  soon  as  the  mouth  of  the  womb  is  sufficiently  open  to  admit  the  four 
fingers  and  thumb  as  far  as  their  second  joint,  we  may  expect  that  it  will 
offer  but  a slight  impediment  to  the  passage  of  the  hand,  and  it  would  be 
unwise  to  delay  the  delivery  until  the  perfect  dilatation  of  the  organ ; be- 
cause, while  we  are  procrastinating,  the  very  accident  may  happen  which 
it  is  so  desirable  to  avoid ; — the  membranes  may  give  way,  the  liquor 
amnii  may  flow  out,  and  the  uterine  parietes  may  strongly  contract  round 
the  foetal  body.  Plate  XLV.  fig.  129.  It  is  possible,  however,  that  be- 
fore the  os  uteri  have  attained  the  diameter  I have  just  specified,  while  we 
are  anxiously  watching  the  progress  of  the  case,  the  membranes  may 
unexpectedly  break.  Under  this  unfortunate  occurrence,  even  though  we 
should  have  some  difficulty  in  dilating  the  os  uteri,  we  must  proceed  to! 
the  delivery,  if  it  can  be  effected  without  injury.  It  is  better  that  we 
should  act  thus  than  wait  patiently  for  a greater  dilatation,  during  which* 
supineness  on  our  part,  the  lapse  of  every  minute  is  adding  to  the  danger 
and  distress  incidental  to  the  case. 

The  principal  difficulty  in  operating  previously  to  the  rupture  of  the 
membranes  will  usually  be  found  to  consist  in  the  dilatation  of  the  os  uteri, 
the  external  parts,  and  the  vagina : the  difficulty  afterwards  is  not  so  much 
in  passing  the  hand  up  to  the  mouth  of  the  womb,  as  in  introducing  it  fully, 
into  the  cavity ; and  the  difficulty  of  dilating  the  orifice,  unless  preternatu- 
rally  rigid,  is  trifling  in  comparison  with  that  of  overcoming  the  strength , 
of  the  uterine  contractions. 

I have  remarked  that  the  uterine  aperture  has  been  more  difficult  of  di- 
latation when  the  labour  wjis  premature : and  I attribute  the  resistance 
offered  to  the  introduction  of  the  hand,  under  such  a case,  to  the  imper- 
fectly developed  state  of  the  cervix,  rather  than  to  any  spasmodic  action 
in  the  fibres  of  the  os  uteri  itself. 

Mode  of  turning  by  the  feet. — In  the  conduct  of  a case  of  this  kind,  then, 
it  is  very  possible  that  in  our  first  examination  we  may  not  detect  positively 
the  nature  of  the  presentation,  because  the  child  lies  too  high  for  us  to 
reach  it  easily ; but  if  we  find  this  the  case,  and  that  the  membranes  are 
coming  down  in  the  form  of  the  finger  of  a glove,  these  two  suspicious 


OPERATION  OF  TURNING. 


311 


circumstances  may  awaken  in  our  mind  a well-grounded  fear  that  it  is  a 
transverse  presentation.  So  long  as  we  are  in  doubt,  we  must  watch  the 
case  attentively,  and  by  no  means  leave  the  house,  even  though  the  os 
uteri  should  not  have  acquired  the  diameter  of  a shilling.  But  when,  in 
process  of  time,  we  have  become  assured  that  the  child  lies  transversely, 
we  need  not  exhibit  any  indication  of  anxiety  or  alarm ; we  must  evade 
the  patient’s  solicitous  inquiries  as  to  the  fairness  of  the  case , by  some  ge- 
neral reply,  and  hold  ourselves  in  readiness  to  act  with  promptitude,  should 
the  bag  of  waters  break,  or  any  other  untoward  occurrence  take  place. 
At  the  same  time,  however,  that  we  keep  her  in  ignorance  of  the  unfortu- 
nate position  of  the  child,  it  is  right  that  we  should  apprise  her  friends  that 
it  is  “a  cross-birth;”  that  there  are  no  dangerous  symptoms  at  present; 
that  she  will  require  to  be  delivered  by  art  before  the  labour  can  be  termi- 
nated ; and  that  the  delivery,  as  it  must  be  an  artificial  one,  will  neces- 
sarily be  attended  with  hazard.  After  this  explanation,  if  a consultation 
be  required,  it  is  much  better  to  acquiesce  than  take  the  risk  of  the  event 
entirely  on  ourselves. 

Having  conscientiously  discharged  this  part  of  our  duty,  it  is  not  de- 
sirable that  we  should  be  in  constant  attendance  by  the  bed-side  of  the  pa- 
tient, nor  make  frequent  examinations,  lest  we  should  rupture  the 
membranes.  We  have  gained  all  the  information  we  want;  we  cannot  at 
present  afford  any  assistance,  and  we  may  do  irreparable  mischief.  We 
should  pass  our  finger  however,  occasionally,  in  the  absence  of  pain,  to 
satisfy  ourselves  as  to  the  degree  of  dilatation  that  has  taken  place ; and 
when  the  os  uteri  will  readily  admit  the  extremities  of  the  four  fingers  and 
thumb  as  far  as  the  second  joint,  we  are  warranted  in  commencing  the 
operation.  For  the  first  time,  we  must  now  tell  the  patient  that  the  child 
is  not  presenting  in  the  most  favourable  manner,  but  that  we  are  about  to 
remedy  its  unfortunate  position ; and  we  may  assure  her,  should  she  press 
the  subject,  that  what  we  shall  do  will  not  place  her  in  danger;  and  that 
she  will  not  experience  more  pain  in  the  aggregate  than  if  the  presentation 
were  natural,  although  it  may  be  a little  more  acute  for  a short  time. 

In  proceeding  to  the  operation,  the  first  thing  to  be  attended  to  is  the 
position  of  the  patient,  and  the  second,  that  she  should  be  confined  to  a 
certain  posture,  so  that  she  may  not  be  able^to  move  out  of  our  reach. 
Unless  we  put  her  in  a favourable  position,  we  might  as  well  expect  to 
extract  a stone  from  the  bladder  with  the  knees  close  together,  as  hope  to 
effect  a safe  delivery.  Dewees,*  following  Baudelocquef  and  other  conti- 
nental practitioners,  recommends  that  she  should  lie  upon  her  back,  with 
the  nates  brought  to  project  somewhat  over  the  edge  of  the  bed,  and  the 


* System  of  Midwifery,  parag.  682. 


t Parag.  1135  translation. 


312 


TRANSVERSE  PRESENTATIONS. 


feet  supported  by  two  chairs  at  a convenient  distance;  the  legs  being  se- 
parated,  and  the  knees  bent.  I cannot  but  think  that  this  posture  would 
be  very  irksome  and  distressing  to  the  woman,  as  well  as  inconvenient  tc 
the  operator ; and  I much  prefer  the  position  adopted  universally  in  this 
country, — which  is,  indeed,  that  commonly  taken  under  labour, — on  the 
left  side,  with  the  knees  drawn  up  towards  the  abdomen,  and  the  feel 
resting  against  the  bed-post.  The  only  alteration  required,  is  that  she 
should  be  brought  near  the  edge  of  the  bed,  that  we  may  have  her  per- 
fectly under  our  command.  The  next  point  is  to  restrain  her  in  this  po- 
sition; and  this  we  may  accomplish  without  her  knowing  that  we  are 
confining  her  at  all.  We  should  request  a friend  to  take  hold  of  her  hand ; 
so  as  to  steady  the  shoulders.  Women  know  that  in  common  labour, 
when  the  expulsive  pains  come  on,  they  are  much  assisted  by  fixing  the 
upper  part  of  their  person,  through  the  means  of  a towel  fastened  to  some 
unyielding  point;  and  they  therefore  seldom  object  to  grasping  the  hand  of 
a friend  instead.  We  must  not  fail,  however,  to  give  this  assistant  a pre- 
vious intimation  to  resist  any  efforts  which  she  may  make  to  draw  herself 
away.  The  nurse  must  then  raise  the  right  knee,  and  separate  the  legs ; 
by  which  also  the  pelvis  is  steadied  in  one  situation ;— and  unless  the  pa- 
tient makes  a violent  effort,  she  is  not  likely  to  move  far  away.  The 
operator  must  take  off  his  coat,  for  without  this  precaution  he  will  neces^, 
sarily  be  foiled  : if  he  simply  bends  back  the  cuff,  the  hand  is  only  admitted 
half  within  the  uterus,  and  no  advantage  can  be  gained ; should,  indeed, 
the  sleeve  even  allow  of  being  turned  up  above  the  elbow,  it  compresses 
the  biceps,  cramps  the  other  muscles,  and  prevents  the  free  motion  of  the 
arm.  The  left  arm*  and  hand  must  be  bared,  and  anointed  with  some 

* The  recommendation  that  we  should  use  for  this  operation,  the  left  hand  in  preference  to; 
the  right , is  grounded  on  what  I consider  four  very  valid  reasons,  presuming  that  the  patient! 
is  placed  on  her  left  side.  First,  when  the  tips  of  the  fingers  are  brought  nearly  together,  so- 
that  the  hand  resembles  a cone,  and  forms  somewhat  of  a wedge,  the  left  hand  enters  the 
vagina  more  easily  than  the  right,  passing  upwards  in  the  direction  of  the  axis  of  the  external 
parts.  Secondly,  when  it  is  lodged  in  the  vagina,  fully  occupying  the  pelvis,  the  knuckles  of] 
the  left  hand  adapt  themselves  completely  to  the  cavity  of  the  sacrum,  and  the  hand  itself  ip 
carried  up  to  the  brim  in  the  direction  of  the  axis  of  the  brim,  following  the  curve  of  th£ 
canal.  Thirdly,  when  it  is  passing  the  brim,  while  dilating  the  mouth  of  the  uterus,  and  en 
tering  its  cavity,  it  then  takes  the  direction  of  the  axis  of  the  uterus,  which  lies  with  its  fun- 
dus  forwards,  and  its  mouth  looking  back  towards  the  sacrum.  Fourthly,  when  the  left  hand  i 
is  in  the  uterus,  an  opportunity  is  given  us  of  steadying  the  uterine  tumour  externally  by  the 
right,  carried  between  the  woman’s  thighs  and  placed  on  the  abdomen.  The  consent  between 
the  two  hands  affords  an  infinitely  greater  facility  in  action,  than  could  be  attained  by  the 
aid  of  any  assistant.  An  act  of  volition  is  all  that  is  required  in  order  to  a co-operation  of 
these  two  members;  the  mind  begets  the  thought,  and  at  the  same  moment  the  limb  per-  j 
forms  the  deed  willed.  But  if  we  have  to  give  directions  to  a party  standing  by,  time  is  lost,  i 
the  progress  of  our  proceedings  is  interrupted,  and  the  probability  is  that  our  orders  will  b« 
obeyed  in  an  imperfect  and  faulty  manner.  If  the  right  hand  be  attempted  to  be  passed  into 


OPERATION  OF  TURNING. 


313 


unctuous  application ; care  being  taken  not  to  grease  the  inside  of  the  fin- 
gers, or  the  palm.  Kneeling  then  by  the  bed-side,  rather  than  sitting,  he 
must  bring  the  tips  of  the  fingers  and  thumb  close  together,  nearly  into  the 
same  level ; and  thus,  forming  the  hand  into  the  shape  of  a cone,  com- 
mence the  process  of  dilating, — with  the  utmost  delicacy  and  caution, — 
first  the  external  parts,  next  the  vagina,  and  lastly  the  os  uteri  itself. 
While  thus  introducing  the  hand,  it  is  better  not  to  pause  until  it  be  fairly 
passed  within  the  uterine  mouth, — unless,  indeed,  more  than  ordinary  op- 
position be  experienced, — and  he  must  by  no  means  withdraw  it,  lest  he 
lose  the  advantage  he  has  already  gained;  he  must  therefore  be  prepared 
to  withstand  the  entreaties  of  his  patient  that  he  should  desist  from  the 
attempts  he  is  making. 

The  stimulus  of  the  hand  will  most  probably  occasion  an  accession  of 
uterine  contraction,  and  the  membranes  will  be  protruded  downwards 
against  the  extremities  of  the  fingers,  and  burst  without  any  effort  on  the 
part  of  the  attendant.  A small  quantity  of  liquor  amnii  will  escape  exter- 
nally ; but  as  the  pelvis  is  more  or  less  occupied  by  the  hand  and  arm,  a 
plug  is  formed,  which  prevents  the  entire  evacuation  of  the  water  ; so  that 
this  fluid  being  retained  in  the  uterus,  permits  the  child  to  make  a perfect 
and  easy  evolution.  The  membranes  being  broken,  the  hand  enters  into 
the  centre  of  the  cavity  of  the  ovum,  and  comes  into  immediate  contact 
with  the  foetal  body. 

It  is  not  absolutely  necessary , before  proceeding  to  the  operation, 
minutely  to  ascertain  the  position  in  which  the  foetus  lies — although  to 
have  obtained  such  knowledge  might  be  desirable;  for  the  fingers  being 
carried  round  to  the  chest,  the  hand  may  be  slid  along  the  abdomen  until 
one  or  both  feet  be  felt;  they  must  be  firmly  grasped,  and  the  breech  care- 
fully and  slowly  brought  down  into  the  pelvis.  I think  it  highly  desirable 
that  both  feet  should  be  taken  hold  of,  if  they  lie  together  and  can  be 
commanded  by  the  same  effort,  because  the  evolution  is  so  much  more 


the  uterus  while  the  woman  lies  on  her  left  side,  it  will  be  immediately  seen  that  the  knuckles 
are  opposed  to  the  under  surface  of  the  symphysis  pubis,  that  the  tips  of  the  fingers  will  rub 
against  the  cavity  of  the  sacrum,  and  that  the  wrist  must  be  bent  far  backwards,  before  the 
hand  can  enter  the  uterine  cavity.  To  effect  this  object  indeed  we  must  place  ourselves  com- 
pletely behind  the  patient,  which  is  an  awkward  posture  for  ourselves,  and  not  always  to  be 
accomplished.  It  may  be  answered,  that  as  the  right  hand  is  used  by  most  persons  in  the  or- 
dinary occupations  of  life,  in  preference  to  the  left,  they  therefore  have  recourse  to  it  in  all 
acts  requiring  any  nicety  of  manipulation.  But  the  greater  degree  of  command  which  we 
possess  of  one  hand  over  the  other  is  almost  entirely  the  effect  of  habit ; and  every  young  sur- 
geon should  accustom  himself  to  use  each  in  many  offices  connected  with  his  profession, — 
such  as  bleeding  for  example, — indiscriminately.  If  he  follows  this  advice,  he  will  soon  find 
himself  as  apt  with  his  fcfl  hand  as  his  right. 

40 


314  TRANSVERSE  PRESENTATIONS. 

easily  accomplished  when  both  are  brought  down ; but  if  one  only  b< 
obtained,  it  is  neither  necessary  nor  proper  that  we  should  spend  time 
and  inconvenience  our  patient,  by  searching  for  the  other.*  The  breed 
being  in  the  pelvis,  the  principal  difficulty  of  the  case  is  over ; it  is  reducec 
to  one  of  the  first  order  of  preternatural  presentations,  and  must  be  termi 
nated  by  the  rules  before  laid  down.  Some  have  recommended  that,  afte 
the  feet  are  extracted,  we  should  leave  the  case  to  be  concluded  by  uterine 
action ; but  the  highest  authorities  all  agree  that  it  is  better  to  terminate; 
it  by  a continuance  of  artificial  efforts— gently,  tenderly,  and  cautiously 
applied— taking  advantage  of  the  assistance  of  the  pains,  and  avoiding  al 
hurry  or  violence. 

Simple  and  easy  as  this  operation  may  be  to  an  expert  hand,  it  is  by  nci 
means  unlikely  that  a younger  practitioner  will  become  somewhat  emban 
rassed ; and  there  are  some  other  points,  therefore,  to  which  we  must  devote 
a portion  of  our  attention,  besides  the  precepts  already  given. 

In  all  instances  where  it  becomes  necessary  to  form  this  artificial 
change  in  the  situation  of  the  foetus,  a piece  of  strong  tape  should  be  pro-1 
cured,  at  one  end  of  which  a running  noose  must  be  made,  to  be  applied] 
if  requisite,  over  the  foetal  ankle  ; Plate  XLIV.  fig.  127 ; for  this  will  assist 
us  materially  in  bringing  down  the  breech,  provided  any  difficulty  be 
experienced  in  causing  the  child’s  body  to  revolve.  This  is,  indeed,  parti 
cularly  useful,  and  almost  indispensable,  when  the  operation  is  performed! 
under  a strongly-contracted  uterus ; and  its  mode  of  adaptation  will  be 
discussed  when  such  cases  come  under  review. 

Again,  before  proceeding  to  the  operation,  it  is  right  that  we  should) 
satisfy  ourselves  that  the  bladder  is  empty;  and  if  distended,  it  should  be  eva 
cuated,  either  by  the  voluntary  efforts  of  the  patient,  or  by  the  catheter; 
We  are  recommended  by  some  practitioners, f indeed,  to  throw  ; 
into  the  rectum  in  all  cases,  as  well  as  draw  oft'  the  urine.  If  th 
be  much  loaded,  such  a precaution  may  be  highly  proper,  for  th. 
of  ensuring  as  much  room  in  the  pelvis  as  possible,  but  ordinal 
not  be  required ; and  if  not  necessary,  may  be  hurtful,  partly  b 
eating  Gur  duty,  partly  by  the  loss  of  time  which  must  attend  its 

* Mr.  Radford,  of  Manchester,  whose  great  experience  in  difficult  cases  of  obstr 
renders  his  opinions  highly  valuable,  counsels  us  “never  to  bring  down  more  tha 
the  manual  operation  of  turning  (Essay  4th,  on  Difficult  Parturition,  p.  15  :) 
other  thigh,  being  flexed  upon  the  abdomen,  offers  a larger  circumference  tha< 
extracted,  and  thus  prepares  the  passages  for  the  more  easy  transit  of  the  shoulde  - . ad  | 
The  advantage  of  this  practice  consists  in  its  affording  greater  safety  to  the  child 
vantage,  in  its  creating  more  difficulty  in  accomplishing  the  evolution. 

t Barlow  (Op.  Cit.,  p.  210)  says,  « On  all  occasions  when  tike  introduction  oft  '•  I 

the  uterus  is  required,  it  is  necessary  that  the  contents  of  the  bladder  and  rectum  . • i 

emptied.” 


OPERATION  OF  TURNING. 


315 


tration,  but  principally  from  the  stimulus  which  may  be  propagated  to  the 
uterus,  and  which  may  excite  increased  action  in  that  organ — a circum- 
stance we  should  be  solicitous  to  avoid,  at  least  before  the  introduction  of 
the  hand. 

Nor  is  it  of  small  importance  that  we  should  be  perfectly  certain  that 
it  is  a foot  we  have  grasped,  before  proceeding  to  extract ; for  if  we  allow 
ourselves  to  be  thrown  off  our  guard  by  agitation,  or  anxious  to  finish  the 
delivery,  are  seduced  into  reprehensible  haste,  and,  by  mistake,  bring  a 
hand  down  into  the  vagina,  the  shoulder  will  come  to  occupy  the  brim  ; 
the  foetus  will  still  be  transverse,  and  we  shall  have  to  renew  our 
attempts  at  “ turning  99  under  very  much  increased  difficulties.  The 
two  limbs  may  be  discriminated  from  each  other  by  the  marks  before 
enumerated.  (Page  306.) 

After  the  arguments  already  used,  it  is  unnecessary  for  me  to  impress 
the  caution,  that  force  in  the  introduction  of  the  hand,  being  never  called 
for,  is  to  be  deprecated  in  the  liveliest  terms;  that  hurry  in  the  extraction 
of  the  child  is  not  desirable,  and  seldom  necessary;  and  that  nothing  can 
warrant  us  in  having  recourse  to  violence.  And  I trust  1 may  be  excused 
for  insisting  on  the  necessity  of  the  hand  being  directed  by  the  mind,  even 
in  the  most  trifling  of  our  proceedings ; and  for  conjuring  the  young  prac- 
titioner ever  to  bear  in  remembrance — during  this  as  well  as  all  other 
obstetrical  operations — the  delicacy  of  the  structures  within  which  he  is 
acting. 

Turning  when  the  uterus  is  contracted  round  the  body  of  the  child. — 
The  operation  of  turning  when  the  uterus  is  strongly  contracted,  is  one 
sometimes  of  considerable  difficulty ; and  under  such  circumstances  the 
infant  is  seldom  saved.  It  will  rarely  occur  to  the  experienced  practi- 
tioner to  meet  with  an  aggravated  case  of  this  nature,  when  he  has  had 
the  conduct  of  it  from  the  commencement;  because  he  will  most  likely 
have  detected  the  position  of  the  foetus  before  the  membranes  break,  and 
will  have  seized  the  first  favourable  opportunity  for  rectifying  its  unfortu- 
nate situation.  But  being  called  when  the  waters  have  been  some  time 
discharged,  it  will  become  a question  for  careful  deliberation,  whether  we 
shall  leave  the  case,  in  the  hope  and  expectation  that  the  child  will  pass 
double ; or  whether  we  shall  attempt  to  assist  Nature  under  difficulties 
which  we  fear  she  will  be  unable  to  surmount.  As  it  would  be  unsafe  to 
trust  the  delivery  to  Nature,  we  must  accomplish  it  artificially;  and  we 
may  either  proceed  to  its  completion  immediately,  or  prepare  the  patient 
previously,  by  attempting  to  lessen  the  powerful  action  of  the  uterus.  On 
this  question  the  opinion  of  practical  men  is  divided — some  advising  us 
not  to  delay  a minute,  others  declaring  that  we  should  run  the  risk  of 
injuring  the  uterus  if  we  attempted  to  pass  the  hand  during  its  contracted 


316 


TRANSVERSE  PRESENTATIONS. 


state ; and  that  therefore  we  ought  to  stay  our  endeavours  until  we  have 
obtained  that  truce  which  is  so  desirable,  and,  indeed,  necessary  : — and  the 
instructions  of  each  party  are  perhaps  applicable  to  certain  peculiar  cases, 
and  therefore  within  certain  limitations  to  be  followed.  I am  myself  an 
advocate  for  the  operation  being  performed  as  early  as  is  compatible  with 
the  woman’s  safety ; and  1 have  almost  invariably  found  that  if  due  cau- 
tion be  observed,  it  can  be  accomplished  without  the  necessity  of  placing 
her  under  that  severe  and  rigid  system  of  treatment  deemed  requisite  by 
some. 

The  advocates  for  the  practice  of  delay  in  those  cases  where  the  foetal 
body  is  strongly  compressed  by  the  powerfully-contracted  uterus,  instruct 
us  to  abstract  twenty  or  thirty  ounces  of  blood,  so  as  to  occasion  syncope; 
and  to  avail  ourselves  of  the  state  of  relaxation  which  it  is  presumed  will 
follow,  for  the  fulfillment  of  our  intention.  If,  notwithstanding  the  super- 
vention of  faintness,  we  cannot  succeed  in  introducing  the  hand,  to  employ 
that  agent  which  is  supposed  to  rank  second  in  effect  in  relaxing  uterine 
contractions,  softening  rigid  fibre,  and  overcoming  clonic  spams — opium : 
we  are  taught  to  exhibit  eighty  or  one  hundred  drops  of  laudanum  imme- 
diately; and,  waiting  a little  for  the  operation  of  the  drug,  to  make 
another  attempt.  If,  after  the  lapse  of  some  time,  we  are  still  unable  to 
insert  the  hand,  we  are  recommended  to  exhibit  twenty  or  thirty  drops 
more  at  intervals,  till  we  find  that  relaxation  has  taken  place.  The  use 
of  poppy  fomentations  to  the  vulva  is  advised ; and  it  is  also  suggested, 
that  where  practicable  we  might  try  the  relaxing  power  of  the  warm  bath. 
The  tobacco  enema  is  spoken  of  as  being  one  of  the  most  likely  means  to 
produce  relaxation ; although  dreaded  as  a highly  dangerous  remedy. 
Failing,  however,  to  effect  our  object  by  these  various  means,  it  is  then 
recommended  that  we  should  wait  till  the  uterus  is  worn  out  by  its  own 
powerful  contractions,  and  that  we  should  take  advantage  of  the  om>f"de 
induced  by  exhaustion.* 

Notwithstanding  the  high  names  by  which  these  measures  con 
mended  to  our  notice,  from  most  of  them  I entirely  dissent,  and, 
think  it  my  duty  to  deprecate  their  use;  because  it  is  not  so  mm 
mediate  delivery  of  the  patient  that  we  have  in  view,  as  her  ultirm 
If,  then,  by  such  means  as  bleeding,  opium,  tobacco,  or  any  othe 
ing  or  narcotic  agent,  we  bring  the  system  into  such  a torpid 
completely  to  remove  uterine  contraction,  we  deprive  the  woma 
very  power  which  is  to  place  her  in  safety  after  her  delivery 
prevent  the  closure  of  the  uterine  vessels,  a patulous  state  of  w 
lead  to  fearful  haemorrhage.  I cannot  help  thinking  that  if  we  c. 


See  Blundell’s  Obstetricy,  by  Castle,  p.  402. 


OPERATION  OF  TURNING. 


317 


patient  either  while  under  syncope  from  bleeding,  or  stupefaction  from 
opium  or  tobacco,  we  should  be  emptying  the  uterus  at  a time  when  it 
could  not  exert  its  contractile  energies ; we  should  consequently  leave  it 
in  a flaccid  state,  and  bring  the  patient  into  the  greatest  peril.  Besides,  I 
very  much  doubt  the  power  of  these  means  to  ensure  the  end  proposed  ; 
for  it  is  not  only  the  occasional  action  of  the  uterus  which  prevents  the 
introduction  of  the  hand,  but  the  permanent  contraction  of  its  fibres,  which 
is  induced  by,  and  consequent  upon,  that  occasional  action.  When  the 
difficulty  merely  arises  from  the  violence  of  the  labour  pains,  we  may 
gradually  insinuate  the  hand  during  the  interval  of  action ; but  when  a 
•permanent  decrease  in  the  capacity  of  the  uterine  cavity  has  taken  place, 
through  a continuance  of  that  occasional  or  intermitting  action  consti- 
tuting the  throes  of  parturition,  a state  of  tonic  contraction  is  induced, 
which  is  constant  and  unyielding,  and  which  it  would  be  fruitless  to  endea- 
vour to  remove  either  by  bleeding,  opiates,  or  any  other  antispasmodic 
power.  Of  all  the  expedients  spoken  of,  bleeding  and  fomentations  are 
perhaps  the  only  ones  which  I would  be  inclined  to  employ ; and  these 
not  with  the  view  of  taking  oflf  uterine  contraction,  but  of  subduing  inflam- 
mation of  the  structures  consequent  on  pressure. 

Should,  then,  this  reasoning  be  correct,  and  should  the  means  so  confi- 
dently recommended  prove  of  little  or  no  avail,  they  must  be  injurious  in 
the  same  proportion  as  they  depress  the  system,  and  it  would  be  unwise  to 
rely  upon,  or  indeed  to  adopt  them ; especially  as  other  modes  of  delivery 
are  placed  within  our  reach, — when  judiciously-directed  efforts  at  turning 
fail, — without  subjecting  the  patient  to  such  additional  causes  of  dan- 
ger.* 


* The  observations  I have  ventured  to  make  in  the  text  are  not  founded  on  speculative 
reasoning1,  but  arc  the  result  of  somewhat  extended  practice.  Between  the  years  1823  and 
1834,  I delivered  more  than  one  hundred  and  twenty  women  under  transverse  presentations, 
independently  of  a few  cases  to  which  I was  summoned  where  spontaneous  evolution  occurred. 
Many  of  these  cases  presented  a formidable  appearance ; for  in  one,  the  membranes  had  been 
ruptured  a whole  week  ; in  another,  sixty-nine  hours  ; in  a third,  fifty-eight  hours  ; in  another, 
fifly-five;  in  another,  fifty-three;  and  in  many,  more  than  forty-eight  : and  as  a general  princi- 
ple, we  presume  that  the  longer  the  liqour  amnii  has  been  evacuated,  the  more  likely  is  the 
uterus  to  have  embraced  the  foetal  body  firmly,  and  the^more  difficulty  will  there  be  in  over- 
coming the  resistance.  In  none  of  these  cases  did  I exhibit  large  doses  of  opium,  and  in  those 
few  where  bleeding  was  practised,  that  operation  was  had  recourse  to,  not  for  the  purpose  of 
relaxing  the  rigidity  of  the  uterine  fibres,  but  to  relieve  the  inflammation  which  the  soft 
structures  were  suffering,  and  to  remove  tumefaction.  In  not  one  of  these  instances  was  any 
injury  inflicted  on  the  uterine  structure  ; nor  did  any  permanent  evil  arise  as  a consequence 
of  the  operation.  In  four  cases  only  was  the  uterus  so  powerfully  contracted  as  to  refuse 
admittance  to  the  hand,  and  compel  me  to  adopt  the  alternative  of  exviscerating  or  decapi- 
tating the  foetus.  I have  instanced  eleven  years  only,  because  since  that  period  I have  not 
had  leisure  to  reduce  to  a tabular  form  the  result  of  my  practice,  and  therefore  cannot  speak 
with  positive  certainty  in  regard  to  the  details. 


318 


TRANSVERSE  PRESENTATIONS. 


Feeling  so  strongly  on  this  subject,  1 think  it  my  duty  to  recommend 
that,  in  all  cases  where  the  membranes  have  been  broken  for  some  time, 
delivery  should  at  once  be  proceeded  in,  provided  the  vagina  and  vulva  be 
relaxed,  and  not  swollen  from  inflammation,  and  provided  the  os  uteri 
also  be  fully  open:  and  if  the  endeavours  of  the  attendant,  judiciously 
directed  and  steadily  persevered  in,  be  frustrated,  that  he  should  pause, 
and  consider  carefully  and  attentively  every  circumstance  connected  with 
the  case ; that  he  may  inform  himself  of  the  particular  cause  of  the  extra- 
ordinary difficulty  he  experiences.  I would  only  again  urgently  caution 
every  young  practitioner  against  using  undue  exertion — against  en- 
deavouring to  overcome  the  resistance  by  force  or  sudden  jerks,  rather 
than  by  a continuance  of  gentle  means — and  against  forming  a resolution 
to  deliver  by  turning  at  all  hazards ; and  I am  persuaded,  if  the  recommen- 
dations hereafter  to  be  submitted,  be  followed,  he  will  be  able  to  effect  the 
requisite  change  in  the  position  of  the  foetus,  and  avert  the  necessity  of 
having  recourse  to  the  severe  measures  adverted  to — provided,  indeed,  the 
version  can  be  accomplished  at  all. 

Mode  of  'performing  the  operation. — Although,  when  speaking  of  turning 
the  child  while  the  uterus  was  still  distended  with  the  waters  of  the  ovum, 
I stated  it  as  my  opinion  that  it  was  not  absolutely  necessary  to  acquaint 
ourselves  positively  with  the  peculiar  position  of  the  foetus — both  because 
when  the  hand  is  introduced  into  the  uterine  cavity  it  can  be  carried 
easily  along  the  body  of  the  child  until  one  or  both  feet  be  felt,  and  because 
of  the  difficulty  of  detecting  the  exact  mode  in  which  it  lies  previously  to 
the  rupture  of  the  membranes — the  case  is  very  different  when  the  uterus 
is  strongly  contracted ; it  then  behooves  us  to  ascertain  most  distinctly 
its  situation  before  we  attempt  to  remedy  it : and  this  information  it  is  not 
difficult  to  gain,  by  observing  which  hand  protrudes,  and  attending  to  the 
direction  of  the  palm.  We  know  the  right  hand  by  the  thumb  being  op- 
posed to  our  own  when  we  place  the  palms  together ; and  we  know  that 
the  palm  of  the  child’s  hand  must  be  looking  in  the  same  direction  as  thfll 
abdomen,  unless  the  arm  be  twisted.  Thus,  then,  if  the  right  hand  be  e* 
ternal,  with  the  palm  directed  anteriorly,  the  head  must  be  lying  on  tW- 
right  ilium,  and  the  face  must  be  looking  forwards : if  the  right  hand  bft 
down,  with  the  palm  towards  the  anus,  the  head  must  be  placed  on  the 
left  ilium,  and  the  face  turned  towards  the  spine : if  the  left  hand  be  pro- 
truded, with  the  palm  forwards,  the  head  must  be  on  the  left  ilium,  and 
the  face  looking  to  the  abdominal  muscles ; and  if  the  left  palm  be  directed 
backwards,  the  head  must  be  on  the  right  ilium  with  the  face  towards  the 
spine.  Having  learned,  then,  on  which  side  the  head  lies,  we  know  that 
on  the  opposite  we  shall  find  the  breech ; and  having  ascertained  whether 
the  face  is  situated  anteriorly  or  posteriorly,  we  know  also  that  towards 


OPERATION  OF  TURNING. 


319 


the  same  part  of  the  uterus  we  shall  encounter  the  legs ; and  thus,  so  far 
as  guiding  our  hand  immediately  to  the  child’s  feet  is  concerned,  our  ope- 
ration is  much  simplified. 

But  it  is  possible  that  neither  of  the  fcetal  hands  may  be  protruded  exter- 
nally, although  the  membranes  may  have  been  ruptured  for  some  hours, 
and  the  shoulder  maybe  fully  occupying  the  pelvic  brim  ; — the  elbow  may 
be  situated  in  the  vagina  doubled.  Under  this  state,  it  might  be  difficult 
to  distinguish  the  right  from  the  left  extremity,  by  making  our  observa- 
tions on  the  arm  itself  alone;  and  it  is  much  better  quietly  and  tenderly  to 
unbend  the  limb,  so  as  to  bring  the  hand  down,  than  to  commence  the  ope- 
ration in  ignorance  of  such  an  important  point. 

It  may  perhaps  be  asked,  why  should  we  bring  down  the  arm,  and  im- 
pede the  subsequent  steps  of  the  operation  by  filling  up  the  pelvis  with  the 
limb? — I would  answer,  that  it  is  not  the  arm  which  prevents  us  making 
the  evolution ; it  is  the  shoulder  and  the  body  of  the  child  blocking  up  the 
pelvic  brim,  together  with  the  strength  of  the  uterine  contractions:  it  is, 
indeed,  of  little  consequence  whether  the  hand  is  external,  or  whether  the 
arm  is  doubled,  the  elbow  presenting  in  the  vagina.  And  if  we  have  any 
doubt  as  to  whether  the  presenting  limb  be  the  right  or  the  left  arm,  it  ap- 
pears to  me  the  best  practice  with  care  to  bring  it  fully  down. 

Some  practitioners  advise,  that  if  the  palm  be  looking  towards  the  mons 
reneris — inasmuch  as  the  feet  must  then  be  placed  anteriorly  in  the  uterus 
— the  right  hand  will  be  more  conveniently  used  than  the  left;  because 
.hat  hand,  traversing  the  fore  part  of  the  uterine  cavity,  passes  up  at  once 
:o  the  very  spot  where  the  feet  lie.*  If  the  right  hand,  indeed,  adapted 
itself  as  well  to  the  axis  of  the  external  parts,  to  the  curve  of  the  sacrum, 
ind  to  the  axis  of  the  uterus,  as  the  left  does,  it  would,  no  doubt,  be  much 
preferable : but  as  this  is  not  the  case,  and  as,  by  simply  directing  the  left 
forwards,  through  rotation  of  the  wrist,  upon  its  admission  within  the 
bavity,  we  can,  without  much  difficulty,  reach  the  feet,  I am,  even  in  this 
position,  inclined  to  recommend  its  employment. 

I'We  will  suppose,  then,  we  are  consulted  in  a case  of  this  serious  diffi- 
culty* where  the  membranes  have  been  ruptured  for  some  hours,  the  hand 
protruded  externally,  swollen,  and  somewhat  livid ; the  shoulder  and  chest 
occupying  the  brim  of  the  pelvis,  and  the  uterus  contracted  powerfully 
around  the  child’s  body.  Having  ascertained  the  exact  position  of  the 
foetus,  by  the  direction  of  the  different  parts  of  the  hand,  before  proceeding 

* Velpeau  Treati6  de  l’Art  des  Accoucheaicns,  etfit.  Brux.;  p.388.  Conquest,  Outlines,  1837, 
?.  128,  and  others.  Blundell,  Castle’s  edit.,  p,  394,  without  prescribing  any  fixed  rule,  favours 
hia  practice. 


320 


TRANSVERSE  PRESENTATIONS. 


to  turn,  it  would  be  right  to  make  an  accurate  examination  of  the  abdo- 
men externally ; by  which  we  may  learn  the  degree  of  contraction  that 
the  uterus  has  taken  upon  itself,  and  form  some  opinion  of  the  probable  re- 
sistance we  are  likely  to  encounter.  We  also  make  ourselves  acquainted 
with  the  general  magnitude  of  the  organ,  and  may  judge  whether  the, 
woman  has  advanced  to  near  the  close  of  gestation.  It  is  very  possible 
that  she  may  have  gone  into  ,labour  prematurely;  and  if,  on  placing  the 
hand  on  the  uterine  tumour,  we  find  it  so  small  that  it  has  sunk  considera- 
bly within  the  pelvis,  we  should  relinquish  the  idea  of  an  operation  for  two 
reasons ; first,  because  we  should  be  foiled  in  endeavouring  to  introduce 
the  hand  into  so  small  a space  as  the  cavity  under  such  circumstances 
possesses ; and,  secondly,  because  in  all  probability  the  foetus  will  pass 
doubled.  Should  the  patient  unhesitatingly  inform  us  that  she  is  persuaded 
she  has  not  exceeded  six  and  a half,  or  seven  months,  we  may  then  gene- 
rally trust  the  case  to  nature ; but,  beyond  that  period,  an  operation  will 
mostly  become  requisite. 

The  position  and  general  management  of  the  patient  must  be  such  as  I 
have  before  described.  Having  taken  off  our  coat,  turned  up  our  shirt 
sleeve,  and  anointed  the  left  hand  and  arm  as  far  as  the  elbow,  avoiding 
the  inside  of  the  fingers  and  palm,  we  must  kneel  by  the  bed-side,  and, 
forming  our  fingers  into  the  shape  of  a cone,  we  must  insinuate  them  cau- 
tiously through  the  external  parts,  up  to  the  os  uteri ; then,  laying  the  hand 
flat  upon  the  child’s  person,  we  endeavour  to  introduce  it  either  anteriorly 
or  posteriorly,  according  as  the  feet  lie,  sliding  it  upwards  along  the  foetal 
body.  It  may  sometimes  avail  us,  in  this  step  of  the  operation,  to  raise 
the  shoulder  somewhat  from  its  position ; but  this  is  generally  difficult  to 
accomplish,  and  not  without  its  dangers.  If  the  uterus  be  contracted  pow- 
erfully, and  our  attempts  are  made  without  great  care,  we  may  thrust 
either  our  own  hand  or  the  child’s  body  through  the  uterine  structure,  to, 
the  almost  inevitable  destruction  of  the  patient.  It  is  more  than  probable 
that  the  stimulus  of  our  hand  may  occasion  an  accession  of  uterine  action, 
which  we  are  made  sensible  of  both  by  the  complaints  ,©f  the  woman,  and 
the  propulsion  of  the  child’s  body  downwards : we  must  then  for  the  present, 
desist  from  farther  endeavours,  (keeping  our  hand  flatly  spread  out  on  the 
child’s  body,  lest  the  irregularities  of  the  knuckles  might  injure  the  uterus,) 
and  resume  them  in  the  interval  of  action.  In  this,  way,  by  little  and  little 
— making  progress  slowly,  but  steadily,  only  pressing  forward  in  the  ab- 
sence of  pain,  laying  the  hand  extended  on  the  child’s  person  during  the 
return  of  uterine  action,  preserving  all  the  advantage  we  have  gained,. .and 
being  most  careful  not  to  withdraw  it, — we  carry  it  fully  within  the  ute- 
rine cavity  to  that  part  in  which  the  feet  are  placed : grasping  them  both. 


OPERATION  OF  TURNING. 


32  i 


if  they  lie  together,  or  one  only,  if  there  is  any  difficulty  in  finding  the 
other,  we  tenderly  bring  the  limb  down,  through  the  os  uteri,  into  the 
vagina.  If  the  foetal  body  be  closely  embraced  by  the  contracted  uterus, 
and  especially  if  the  shoulder  be  at  all  wedged  in  the  brim  of  the  pelvis 
we  shall  find  that,  although  the  foot  descends  into  the  vaginal  cavity,  still 
the  shoulder  does  not  recede,  and  the  child  does  not  perform  the  necessary 
version  to  allow  the  breech  to  pass  down  so  as  to  occupy  the  pelvis ; and 
the  greater  exertion  we  make  to  draw  the  foot  outwards,  the  more  firmly 
does  the  shoulder  become  impacted  in  the  pelvic  brim.  It  is  evident,  then, 
unless  we  can  raise  the  shoulder,  that  we  shall  not  procure  a space  into 
which  the  breech  can  descend ; and  if  we  endeavour  to  push  the  upper 
part  of  the  child’s  body  out  of  the  way,  while  we  are  using  no  extractive 
power  to  bring  the  breech  down,  we  shall  not  only  not  succeed  in  our  en- 
deavours, but  the  foot  will  escape  back  again  into  the  uterine  cavity. 
Now,  as  the  vagina  is  not  sufficiently  capacious  to  admit  both  hands  at 
the  same  time, — with  one  of  which  we  might  raise  the  shoulder,  and  with 
the  other  draw  down  the  breech,  by  means  of  the  leg, — it  will  much  assist 
us  to  get  a noose  of  strong  tape  fixed  round  the  ankle,  while  still  in  the 
vaginal  cavity;  nor  shall  we  find  much  difficulty  in  the  adjustment;  and 
when  applied,  traction  downwards,  in  a line  tending  towards  the  coccyx, 
may  be  made  by  it,  while  a steady  pressure  upwards  is  exerted  by  the  ex- 
tremities of  the  fingers  placed  against  the  axilla  or  the  ribs.  By  this 
double  effort  the  shoulder  can  be  raised, — although  that  was  impossible 
before  the  leg  was  brought  down, — because  room  is  made  for  its  recession 
by  the  descent  of  the  breech,  while  at  the  same  time  a space  is  formed  for 
the  reception  of  the  breech  by  the  ascent  of  the  shoulder.  The  breech, 
then,  having  been  made  to  occupy  the  pelvis,  the  case  is  reduced  to  one 
of  the  first  order  of  preternatural  cases,  and  must  be  managed  by  the  rules 
before  inculcated. 

I freely  confess  that  sometimes  it  is  most  difficult,  if  not  impossible,  to 
introduce  the  hand  so  high  into  the  uterus  as  to  arrive  at  the  feet,  because 
they  may  lie  at  its  very  fundus,  and  it  may  be  dangerous  to  attempt  to 
overcome  the  strength  of  the  contraction  which  the  uterus  has  taken  on 
itself.  It  has  happened  to  me,  in  working  the  hand  along  the  body  of  the 
child,  to  have  passed  it  as  far  as  the  breech,  to  feel  the  legs  doubled  up, 
(m|  not  to  be  able  to  reach  a foot.  In  such  a case  I have  not  thought  it 
right  to  make  a strenuous  effort  in  order  to  encompass  the  feet,  but  have 
Satisfied  myself  with  hooking  a finger  in  the  ham,  and  making  the  child 
revolve  by  the  power  that  purchase  afforded.  It  must  not,  however,  be 
overlooked  that  this  practice  is  far  from  being  unattended  with  danger ; 
because  an  arm  may  be  mistaken  for  a leg, — the  bend  of  the  elbow  for 
that  of  a knee ; and  it  would  be  unsafe  for  any  one  to  have  recourse  to  it, 
41 


322 


TRANSVERSE  PRESENTATIONS. 


until  his  experience  enables  him  with  certainty  to  discriminate  the  one 
limb  from  the  other.* 

Spontaneous  evolution. — It  was  a remark  first  prominently  set  forth  b) 
Denman,  that  occasionally,  under  a shoulder  presentation,  after  the  mem- 
branes had  been  broken  some  time,  the  uterus  acting  with  considerable  en 
ergy,  the  body  was  forced  down  into  the  pelvis,  and  an  unassisted  termiria 
tion  of  the  case  occurred,  the  breech  being  expelled  first.  To  this  peculiai 
change  of  position,  effected  by  nature,  he  gave  the  term  “ spontaneous  evolu 
tion and  he  has  supplied  us  with  his  idea  of  the  mode  in  which  it  occurs,  ir 
the  following  passage  :f — “ I presume  that,  after  the  long-continued  actior 
of  the  uterus,  the  body  of  the  child  is  brought  into  such  a compacted  stat< 
as  to  receive  the  full  force  of  every  returning  action.  The  body,  in  it: 
doubled  state,  being  too  large  to  pass  through  the  pelvis,  and  the  uteru: 
pressing  upon  its  inferior  extremities,  which  are  the  only  parts  capable  o 
being  moved,  they  are  forced  gradually  lower,  making  room,  as  they  ar< 
pressed  down,  for  the  reception  of  some  other  part  into  the  cavity  of  th» 
uterus,  which  they  have  evacuated,  till  the  body,  turning,  as  it  were,  upoi 
its  own  axis,  the  breech  of  the  child  is  expelled,  as  in  an  original  presen 
tation  of  that  part.”  He  afterwards  says, — “ Premature  or  very  sma) 
children  have  often  been  expelled  in  a doubled  state,  when  the  pelvis  wa; 
well  formed,  or  rather  more  capacious  than  ordinary ; but  this  is  a diffe 
rent  case  to  that  which  we  are  now  describing,”  The  ideas  that  Denmai 
had  formed  of  this  unusual  occurrence  were  generally  received  by  th 
profession  as  the  true  explanation,  until  Dr.  Douglas  of  Dublin,  in  a pam 
phlet  first  published  in  1811,  showed  clearly  that  the  description  was  incoi 
rect.  He  observes,  “ that  it  is  incompatible  with  the  received  ideas  C 
uterine  action  to  suppose  that  the  uterus,  when  contracting  so  powerful!: 
as  to  force  down  that  part  of  the  child  which  was  at  its  fundus,  could  a| 
the  same  moment  form  a vacuum,  into  which  another  portion,  alread 
low  down  in  the  pelvis,  should  recede.”+  Dr.  Douglas,  then,  first  gave  u 
a true  history  of  the  process ; and  he  has  proved  that  the  foetus  actual!) 
does  pass  the  pelvis  in  a doubled  state,  although  4@fiifed  by  Denman.  B< 

* Campbell  (Mid.  p.  28G)  recommends,  in  all  cases  of  turning-,  that  the  knees  shouj^B 
jp  grasped  instead  of  the  feet;  as  was  first  recommended  by  Dr.  Breen,  Edinburgh  Med.  Surg 
Journal,  voi.  xiv.  jr.  30.  . 

In  one  instance,  when  the  irregular  action  of  the  fibres  of  the  fundus  prevented  my  arriviat 
^at  the  foot,  after  having  passed  my  finger  round  a ham,  not  possessing  sufficient  power  tc 
cause  the  child  to  revolve,  I directed  a small  blunt  hook  by  the  side  of  my  finger,  and  keeping 
the  point  well  guarded,  made  traction  by  it,  and  accomplished  my  purpose;  but  such  a pro 
ceeding  must  be  attended  with  some  risk. 

f Introduction  to  Midwifery,  chap.  xiv.  sect.  8. 

t Explanation  of  the  real  process  of  the  “ Spontaneous  Evolution  of  the  Foetus,”  1819 
p.  27. 


PLXLY 


StTLC-lctli'S  Z/z/'A- 


_Fi#.7Z&. 


LIBRARY 
Eh"  THE  ■ 

UNIVERSITY  OF  (UINOIC 


SPONTANEOUS  EVOLUTION. 


323 


has  described  it,  as  indeed  I myself  have  witnessed,  to  be  accomplished 
in  the  following  manner : — By  the  continuance  of  the  powerful  uterine 
contractions,  the  whole  of  the  arm  is  protruded  externally,  the  shoulder 
and  chest  being  propelled  low  into  the  pelvic  cavity.  The  acromion  then 
appears  under  the  symphysis  pubis ; and  as  the  loins  and  breech  descend 
into  the  pelvis  at  one  side,  the  apex  of  the  shoulder  is  directed  upwards 
towards  the  mons  veneris.  Farther  room  is  thus  gained  for  the  complete 
reception  of  the  breech  into  the  cavity  of  the  sacrum,  and  that  part  of  the 
child’s  body  is  eventually  expelled,  sweeping  the  sacrum,  and  distending 
the  perineum  to  a vast  extent.  As,  during  the  whole  of  this  process,  the 
head  remains  above  the  pelvic  brim,  it  is  evident  that,  the  apex  of  the 
shoulder  being  external,  the  clavicle  must  be  strongly  pressed  against 
the  under  surface  of  the  symphysis  pubis:  on  which  point,  indeed,  the 
foetal  body  partially  revolves,  as  on  an  axis;  the  other  shoulder  and  arm, 
and  the  head,  being  expelled  last.  Plate  XLY.  fig.  128.  The  pelvis  is 
represented  filled  by  the  chest  and  abdomen  of  the  child  ; the  left  shoulder 
below  the  symphysis  pubis ; and  the  breech  entering  the  cavity  within  the 
left  ilium. 

We  cannot  reasonably  expect  this  doubled  expulsion  to  occur,  unless 
the  patient  possess  a larger  pelvis  than  ordinary,  or  unless  the  foetus 
be  preternaturally  small  or  premature ; nor,  indeed,  except  under  a long 
continuance  of  powerful  and  expulsive  pains.  But  the  knowledge  of  the 
fact,  however  rare  its  occurrence,  must  be  considered  of  much  importance 
practically ; for  if  we  saw  good  reason  to  believe  that  delivery  was  likely 
to  be  effected  in  the  manner  just  detailed,  we  might  be  inclined  to  leave 
the  case  to  the  unaided  efforts  of  nature,  and  hope  for  a fortunate  termi- 
nation.* 

But  another  practical  advantage  has  been  also  gained  by  observing  the 
phenomena  that  I have  mentioned — namely,  the  institution  of  an  operation 
in  which  the  process  may  be  imitated,  wherever  it  is  found  impossible  to 
deliver  by  the  more  ordinary  method  of  turning ; and  this  consists  in  di- 
minishing the  bulk  of  the  foetal  body  by  the  removal  of  the  viscera;  an 
opportunity  being  thus  afforded  it  to  collapse,  so  that  it  may  be  extracted 
without  much  difficulty, 

Exvisceration.  It  must  not  be  imagined  that  the'  operation  of  ex  visce- 
rating the  foetus  is  intended  to  supersede  the  practice  of  turning  under 

* 1 have  Personally  known  seven  cases  of  this  description,  in  all  which  my  assistance  was 
desired  ; and  I was  present  at  four  of  them  during  the  expulsion  of  the  fetus  through  the  out- 
let of  the  pelvis.  Three  of  the  children  were  born  alive ; two  of  them  were  twins ; all  the  rest, 
except  one,  (which  was  at  full  time,)  were  premature,  being  expelled  between  the  sixth  and 

seventh  month. 


324 


TRANSVERSE  PRESENTATIONS. 


transverse  presentations.  It  is  only  to  be  had  recourse  to  as  a last  re- 
source, when  many  hours  have  elapsed  since  the  rupture  of  the  membranes 
— when  the  foetal  body  is  so  firmly  wedged  within  the  pelvis,  or  at  the 
brim,  that  the  introduction  of  the  hand  into  the  uterus  is  rendered  impos- 
sible, or  would  be  evidently  attended  with  most  imminent  danger. 

In  modern  times  this  operation  was  first  recommended  by  Douglas,  and 
in  this  city,  I believe,  first  resorted  to  by  my  father.  In  itself  it  is  not 
difficult  of  performance,  and  requires  merely  the  use  of  the  same  instru- 
ments employed  for  perforating  and  extracting  the  head.  The  woman 
lying  on  her  left  side,  an  assistant  should  be  directed  to  bring  the  chest 
as  fully  into  the  pelvis,  by  traction  at  the  arm,  as  possible;  the  perforating 
scissors,  guided  by  two  fingers  of  the  left  hand,  should  be  carried  against 
one  of  the  intercostal  spaces,  and  a free  opening  made.  Plate  XLV. 
fig.  129.  One  or  more  ribs  may  be  divided,  if  necessary,  so  that  two  or 
three  fingers,  or  the  whole  hand,  can  be  introduced  within  the  aperture. 
Through  this  incision  the  contents  of  the  foetal  thorax  must  be  extracted ; 
the  diaphragm  may  be  perforated  afterwards,  and  by  the  same  opening 
the  liver  and  intestines  evacuated.  The  body,  thus  deprived  of  the  prim 
cipal  part  of  its  contents,  will  collapse ; and  if  the  uterus  continues  to  act 
with  vigour,  will  be  expelled  doubled,  the  breech  following  the  curve  of 
the  sacrum  and  perineum.  But  should  the  pains  have  ceased,  artificial 
extraction  may  be  most  beneficially  made  by  means  of  the  crotchet  car- 
ried through  the  opening,  and  fixed  within  the  foetal  ilium ; the  breech  will 
soon  be  observed  to  descend,  and  the  case  will  be  terminated  as  though 
Nature  had  expelled  the  child  unaided. 


Decapitation.— Another  means  of  delivery  under  transverse  presenta- 
tions, when  turning  is  impracticable,  is  afforded  by  the  division  of  the 
cervical  vertebrae,  and  the  separation  of  the  head  from  the  trunk.  This 
operation,  as  well  as  that  last  described,  I have  myself  had  recourse  to,  and 
have  found  the  difficulty  by  no  means  great.  The  best  instrument  foi 
its  performance  is  a.  hook  with  an  internal  cutting  edge,  formed  by  my 
father;  Plate  XLVI.  fig.  130,  and  the  following  is  the  *£st  method  ol 


.using  it.  - , * V - ' * , # • 

The  finger  having  been  passed  around  the  neck,  a large-sized  blunt 
\ togk  must  be  introduced  upon  it,  and  the  presenting  part  must  be  brought 
">a1§DSw  into,  the  pelvis  as  is  consistent  with  the  woman’s  safety.  An 
asliife&t  rhust  then  steady  the  blunt  hook ; the  decapitator  must  be  directed 
over  t$k  neck  by  its  side,  and,— the  first  adapted  instrument  -having  been 
withdrawn,-- -a  sawing  motion  must  be  given  to  the  cutting  hook  by  the 
right  hand,  while  the  first  finger  of  the  left  is  kept  steadily  in  contact  with 
its  blunt  point.  Plate  XLYI.  fig.  131.  It  will  soon  be  found  that  the 


SyJJO. 


fl.XLVI 


S\*uc2cur!r  L ith.. 


LI  BRARy 

" - o,  THE 

vvivmnf  of iLUKorc 


•: 


. 


b .-.4 


• >•  . - 


DECAPITATION. 


325 


structures  give  way,  and  that  the  separation  is  effected.  The  child’s  body 
must  then  be  drawn  out  by  which  ever  arm  may  protrude,  and  the  head 
extracted  by  a crotchet  or  blunt  hook  introduced  into  the  foramen  mag- 
num, or  the  mouth;  nor  will  its  removal  generally  offer  much,  difficulty, 
unless  the  pelvis  be  contracted  in  its  dimensions.  I can  scarcely  suppose 
it  possible  for  any  case  of  transverse  presentation  to  occur,  which  might 
not  be  terminated  by  one  or  other  of  these  operations,  provided  turning 
could  not  be  accomplished; — unless,  indeed,  the  pelvis  be  distorted  in  an 
extreme  degree,  or  almost  fully  filled  by  a solid  tumour.  For  if  the  chest 
be  much  pressed  downwards,  occupying  a large  portion  of  the  pelvic 
cavity, — although  it  would  be  difficult  to  surround  the  neck  so  as  to  am- 
putate the  head, — perforation  of  the  thorax  would  be  easy,  and  delivery 
could  be  perfected  through  its  means : while  if  the  child  presented,  as  oc- 
casionally happens,  with  the  neck  directly  over  the  pelvic  brim,  then  there 
could  be  little  trouble  in  passing  the  finger  round  that  part,  as  a guide  to 
the  cutting  hook ; although  to  perforate  the  chest  under  such  a presenta- 
tion would  be  dangerous  if  not  impracticable. 

Plate  XLV.  fig.  129,  and  Plate  XLVI.  fig.  131,  show  the  mode  of 
performing  these  two  operations.  A front  view  of  the  pelvis  is  given  in 
both  the  illustrations ; but  it  must  be  remembered  that  in  practice  the  wo- 
man must  be  placed  on  her  left  side. 

I can  fully  appreciate  the  horrifying  feelings  with  which  the  reader 
must  be  impressed,  whilst  contemplating  the  details  of  two  operations  ap- 
parently of  the  most  barbarous  and  savage  nature — the  shudder  which  he 
must  experience  on  finding  any  person  hardy  enough  calmly  to  sanction 
and  advise  the  decapitation,  or  disembowelling,  of  a foetus  in  utero. 
Surely,  however,  I need  not  add,  that  such  modes  of  delivery  should 
never  be  thought  of  unless  the  foetus  be  dead ; nor,  indeed,  can  they  ever 
be  necessary  until  life  is  extinct ; for  if  the  chest  be  so  firmly  impacted  in 
the  pelvis  as  to  prevent  the  introduction  of  the  hand  into  the  uterine  cavity, 
the  pressure  to  which  the  heart  itself  would  be  subjected  must  destroy  the 
existence  of  the  foetus,  independently  of  the  great  chance  that  fatal  com- 
pression will  take  place  on  the  umbilical  yessels,  both  in  the  cord,  and 
after  their  division  upon  the  placenta ; so  t|at  our  feelings  on  that  account 

can  never  be  wounded.  -y  S' 

' % 

Many  of  the  ancient  writers*  recommend  tHSt>  when  the  arm  kj  pro- 
truded externally,  it  should  be  amputated  at  the  shoulder-joint : this  prac- 
tice has  been  pursued  in  late  days;  and  I have  known  instances  in;yffij£h 

■ 

* iEtius,  tetrab.  iv.  sermo  iv.  cap.  22  et  23. — Heister,  cap.  153,  parag.  6,  says,  “ Si  vel  prop- 
ter nimis  tumidum  brachium,  vel  propter  uterum  mints  constrictam,  manus  chirurgi  in  uterum 
dcmitti  nequcat,  vel  extorqueri  ex  scapula  articuloy  vel  qtffun  cautissime  rescindi  bracliium 
juxta  hurnerum  oportebit .” 


326 


TRANSVERSE  PRESENTATIONS. 


it  has  been  carried  into  effect.  From  such  a recommendation,  however, 
I most  strenuously  dissent ; because  the  removal  of  the  arm  cannot,  in  the 
slightest  degree,  avail  us  in  farthering  delivery,  and  because  it  has  been 
followed  by  the  most  distressing  consequences.  Thus  Chapman*  gives  an 
instance,  in  which  the  attendant,  supposing  the  child  dead,  amputated 
its  arm  while  in  utero ; it  was  afterwards  born  alive,  and  grew  up  to 
manhood.f 

While  there  is  a possibility  of  the  infant  surviving  such  serious  mutila- 
tion, it  would  be  in  the  highest  degree  injudicious,  not  to  say  criminal,  to 
practice  it : but  another  valid  reason  would  induce  us  to  banish  the  ope- 
ration;— that  the  dismemberment  of  the  child,  in  the  manner  described, 
can  seldom  be  of  the  least  service  in  facilitating  the  delivery  of  the  patient  ; 
for  I have  before  stated  that  it  is  not  the  arm,  partially  occupying  the 
vagina#  which  prevents  the  entrance  of  the  hand  into  the  womb,  but  the 
shoulder  impacted  in  the  pelvic  brim,  and  the  uterine  parietes  strongly 
embracing  the  child’s  body.  Besides,  when  the  arm  has  been  separated, 
such  a confusion  of  parts  is  produced  as  to  render  it  difficult  to  discriminate 
between  the  foetal  and  maternal  structures ; and  should  it  afterwards  be 
found  necessary  either  to  perforate  the  chest,  or  separate  the  head  from 
the  trunk,  we  have  lost  the  means  of  traction  which  the  arm  afforded,  and 
which  assists  us  materially  in  our  operation.  For  all  these  reasons,  then, 
the  custom  of  amputating  the  protruded  limb  is  both  unnecessary  and 
unwarrantable. 

It  may  be  reasonably  anticipated  that  a transverse  position  of  the  foetus 
may  be  complicated  with  a pelvis  distorted  to  such  an  extent  as  to  pre- 
clude the  passage  of  the  hand  into  the  uterus  for  rectifying  its  unfortunate 
situation ; or  so  small  as  to  prevent  its  extraction,  even  if  the  necessary 
evolution  could  have  been  accomplished.  In  such  an  extreme  case,  the 
Caesarean  section  affords  the  only  possible  means  of  delivery. 

* Treatise  on  Midwifery,  1759,  p.  113.  See  also  Chamberlen,  lib.  ii.  chap.  12. 

t A case  of  even  more  aggravated  nature  occurred  in  France  in-the  year  1829.  A practi- 
tioner at  Chenu,  in  the  department  ofOrne,  removed  both  the  arms  of  a child  which  were  pro- 
truded  together,  swollen,  and  livid,  after  having  made  vain  attempts  to  turn  : no  blood  flowed, 
but  the  infant  was  soon  born  alive  ; and  surviving  the  mutilations,  the  wounds  speedily  healed. 
The  father  brought  an  action  against  the  attendant;  and  the  tribunal,  before  which  the  case 
was  tried,  referred  the  matter  to  the  Royal  Academy  of  Medicine  for  their  opinion.  A com- 
mittee of  five  gentlemeu  were  appointed,  consisting  of  MM.  De^pfmeaux,  Gardien,  Deneux, 
Adelon,  and  Moreau;  and  they  drew  up  a report,  strongly  censuring  tfie  defendant : but  it 
met  with  much  opposition  when  discussed  in  the  Academy,  and  was.  feturjJ&L to  the  com- 
mitted for  consideration.  A second  time  their  answer  was  pf  the  same'teYibur,  though  not 
conveyed  in  such  strong  language.  Whether  any  or  what  punishment  was  awarded  by  the 
tribunal  for  this  malpractice,  I am  ignorant. — Lancet,  April  4th,  1829.) 


Order  iv.— COMPLEX  LABOURS. 


Plates  XL VII.,  XLVIII.,  XLIX.,  L.,  LI.,  LII. 


The  class  complex  labours  embraces  ten  orders  ; not,  however,  included 
under  one  head  because  of  any  analogy  that  they  bear  to  each  other,  but 
merely  to  prevent  the  embarrassment  which  might  arise  from  a multipli- 
cation of  separate  and  distinct  classes. 

These  are— -first, labours  complicated  with  haemorrhage;  secondly , with 
convulsions;  thirdly , with  ruptured  uterus ; fourthly f with  lacerated  vagina; 
fifthly , with  ruptured  bladder;  sixthly , with  syncope,  independently  of 
haemorrhage,  or  any  extensive  laceration  or  other  lesion ; seventhly , with 
descent  of  the  funis  by  the  side  of  the  head,  or  breech ; eighthly , with  the 
descent  of  the  hand  by  the  head  or  breech;  ninthly , labours  in  which  mon- 
sters are  brought  forth;  and  tenthly , in  which  there  is  a plurality  of 
children. 


1st.  LABOURS  COMPLICATED  WITH  HAEMORRHAGE. 

Haemorrhage  during  labour. — Haemorrhage  is  by  far  the  most  frequent 
source  of  danger  to  the  lying-in  woman ; and  since  it  is  so  commojy.  in 
occurrence,  so  alarming  in  its  nature,  and  fatal  in  its  effects,  this  accident 
calls  for  the  most  anxious  and  serious  attention. 

It  must  be  borne  in  mind  that  all  profuse  haemorrhages  during  parturi- 
tion, and  towards  the  close  of  gestation,  are  to  be  regarded  as  originating 


328 


COMP  L EX  LABOUR  S. 


in  a partial  detachment  of  the  placenta  from  the  uterine  surface,  and  the 
consequent  opening  of  a certain  number  of  vascular  orifices.  For  although 
some  physiologists*  have  supposed  that  the  vessels  which  communicate 
with  the  decidua  might,  when  a portion  of  that  membrane  became  loosened 
from  its  uterine  connexion,  furnish  a sufficient  quantity  of  blood  to  consti- 
tute an  alarming  discharge,  I cannot  think  but  that  they  have  overrated 
the  consequence  of  such  an  accident;  and  that,  during  the  last  few  weeks 
of  pregnancy  at  least,  we  should  attribute  all  dangerous  floodings  to  a par- 
tial separation  of  the  placental  mass  itself. 

It  is  a common  observation,  and  in  a great  measure  true,  that  the  ear- 
lier in  gestation  haemorrhage  occurs,  the  less  danger  does  it  generally 
bring  with  it ; so  that  an  attack  of  flooding  coming  on,  either  near  the  full 
period  of  pregnancy,  or  during  the  progress  of  labour,  is  by  far  more  fre- 
quently fatal  than  in  the  more  early  weeks.  This  is  owing  to  the  large 
quantity  of  blood  that  may  flow  in  a short  space  of  time,  in  consequence 
of  the  enormous  size  which  the  vessels  have  acquired  towards  the  close  of 
pregnancy.  It  has  been  shown  that,  as  the  uterus  enlarges  in  bulk,  and 
its  cavity  increases  in  extent,  the  blood-vessels  also  undergo  a gradual 
dilatation  in  their  calibre,  and  that,  at  the  end  of  gestation,  the  arteries 
have  acquired  a capacity  sufficient  to  admit  the  barrel  of  a goose-quill 
without  any  difficulty,  and  the  veins  a cylinder  of  even  greater  diameter. 

It  must  also  be  noted,  that  haemorrhage  from  the  uterus,  under  labour, 
is  of  a passive  character ; that  the  blood  escapes,  not  as  a consequence  of 
any  forcible  rupture,  produced  by  the  excessive  action  of  the  heart  and 
arterial  system, — as  is  generally  the  case  in  haemoptysis, — but  merely  by 
being  allowed  to  exude  through  orifices  rendered  patulous  by  the  separa- 
tion of  a substance  which  had  previously  closed  them ; and  that  there- 
fore, when  the  flow  is  immoderate,  our  treatment  must  necessarily  be 
directed  towards  preserving  within  the  body  as  much  of  the  vital  fluid  as 
possible. 

Although  a large  loss  of  blood  is  always  greatly  to  be  ^dreaded,  yet  ir 
practice  we  do  not  so  much  regard  the  quantity  that  flows,  as  the  effect 
which  the  loss  produces  upon  the  constitution  of^tfee  patient ; because  we 
find  that  different  women  vary  very  remarkably  in  their  capabilities  oi 
bearing  up  against  the  results  of  haemorrhage.  It  is  surprising  to  notice 
how  slight  a degree  of  depression  will  follow"  an  excessive  flooding  in 
some  women ; and  how  small  a discharge  will  destroy  others.  I htive 
known  two  women  die  from  the  eruption  of  scarcely  a pint  offfilood ; and 
I have  seen  others  recover  perfectly  when  they  have  suffered  the  loss  of 
some  quarts ; so  that  the  quantity  which  would  constitute  a dangerous 


See  Burns’s  Midwifery,  5th  edition,  p.  287. 


UTERINE  HEMORRHAGE. 


329 


haemorrhage  in  one  constitution,  would  in  another  not  even  produce 
alarm. 

Besides  the  quantity  of  blood  lost,  the  danger  to  the  patient  depends 
also  on  the  celerity  with  which  it  flows.  If  a pint  escape  at  one  gush,  it 
is  usually  followed  by  a state  of  faintness,  and  perhaps  complete  syncope . 
but  a slow  draining  may  go  on  for  a considerable  time,  until,  in  the  whole, 
many  pounds  may  have  oozed  away,  with  but  little  constitutional  distur- 
bance; and  this  difference  may  depend  on  two  circumstances: — In  the 
first  place,  the  arteries  throughout  the  entire  body,  by  the  power  of  con- 
traction inherent  in  their  structures,  accommodate  themselves  in  diameter 
to  the  decreased  quantity  of  their  contents;  and  this  diminution  in  calibre 
they  have  an  opportunity  of  effecting  when  the  blood  drains  away  slowdy, 
but  not  when  it  passes  out  with  greater  rapidity: — and  secondly,  at  the 
same  time  that  the  discharge  is  going  on,  fresh  blood  is  also  formed  by 
the  assimilation  of  nourishment ; and  thus  the  deficiency  is  in  part  at  least 
supplied,  and  a more  equal  balance  is  kept  up. 

But  although  the  immediate  effect  on  the  constitution  is  not  so  great, 
still  we  must  look  with  much  anxiety  on  these  continual  drainings,  for 
they  will  in  time  undermine  the  most  robust  habit;  and  I have  remarked, 
that  women  usually  recover  better  when  a small  quantity  has  suddenly 
broken  forth  in  one  eruption,  than  when  they  have  lost  a larger  quantity 
more  slowly ; although,  in  the  latter  case,  they  may  have  experienced  but 
little  comparative  distress  at  the  time  the  , blood  was  flowing.  Dropsies, 
purgings,  affections  of  the  chest,  and  organic  diseases  of  the  abdominal 
viscera,  have  more  frequently  followed  a draining  continued  for  a length 
of  time,  than  one  sudden  gush,  notwithstanding  that  the  violence  of  the 
shock  in  the  latter  case  may  have  produced  a state  of  syncope  that  was 
alarming  at  the  moment.  The  danger  then  will  partly  depend  on  the 
quantity  lost,  partly  on  the  celerity  with  which  it  flows ; and  must  be 
estimated  by  the  effect  on  the  constitution. 

When  a woman  floods  in  labour,  it  is  very  seldom  that  the  discharge 
will  continue  with  the  same  impetuosity  until  death  supervenes;  but  the 
patient  faints  and  rallies,  and  faints  again : until  at  length  a perfect  syn- 
cope will  paralyze  the  senses,  deaden  the  nervous  energy,  and  put  a stop 
for  ever  to  the  action  of  the  heart.  Occasionally,  indeed,  one  tremendous 
burst  takes  place,  which  so  completely  depresses  the  system,  that  a mor- 
tal faint  at  once  occurs.  The  heart  and  sanguiferous  vessels  become  so 
rapidly  emptied,  that  they  possess  no  longer  the  power  of  contracting 
upon  theiV  diminished  contents,  so  as  to  propel  them  onwards ; and  thus, 
after  making  some  vain  and  futile  efforts  to  keep  up  the  circulation,  their 
action  entirely  ceases,  never  to  be  restored  ; — though  this  is  comparatively 
rare.  Sometimes,  again,  a slow  draining  will  go  on  for  a length  of  time, 
42 


330 


COMPLEX  LABOUR. 


the  faintness  increasing  with  the  loss  of  blood,  the  heart's  action  never 
being  perfectly  suspended  during  the  continuance  of  the  discharge  ; and 
the  first  attack  of  syncope  will  be  the  last. 

Means  adopted  by  nature  to  arrest  hcemorrhage.— Since,  then,  bleedings 
seldom  continue  uninterruptedly  until  death  takes  place,  it  is  clear  that  a 
process  is  established  by  nature  for  the  purpose  of  subduing  hemorrhage. 
When  an  artery  is  wounded,  there  are  four  principal  ways  by  which 
Nature  endeavours  to  put  a stop  to  the  immediate  flow  of  blood ; and  a 
fifth,  by  which  she  renders  the  safety  of  the  patient  permanent.  The  first  i 
philosophical  attempt  to  explain  Nature’s  mode  of  proceeding  in  suppress- 
ing haemorrhage  from  divided  arteries,  was  given  to  the  world  in  1731  by! 
M.  Petit,* * * §  who  accounted  for  it  on  the  principle  of  a coagulum  formed ! 
around,  and  at  the  extremity  of  the  bleeding  vessel,  extending  to  a consi- j 
derable  distance  within  the  cavity  of  the  canal,  lying  partly  within,  and! 
partly  externally;  and  thus  offering  a barrier  to  the  free  flow  of  blood. 
This  opinion  was  in  a few  years  commented  on  by  Morand,f  who  was! 
afterwards  followed  by  Sharp, J Kirkland, § White, ||  Goochl,  and  others.  | 
These  physiologists,  although  they  in  part  subscribed  to  Petit’s  doctrine,! 
insisted  that  the  chief  cause  consisted  in  a change  which  the  artery  itself 
undergoes;  that  change  was  severally  described  as  being  a corrugation, 
or  plaiting,  of  the  circular  fibres  of  the  vessel,  by  which  its  calibre  is  | 
directly  diminished,  together  with  a shortening,  a corresponding  thicken- 
ing of  its  longitudinal  fibres,  and  a retraction  of  the  open  mouth,  which? 
all  indirectly  assist  in  contracting  its  canal.  The  third  opinion  was] 
advanced  by  Pouteau,**  who  attributed  it  to  the  swelling  or  thickening! 
of  the  cellular  substance  surrounding  the  artery;  and  lastly,  the  late  Mr. j 
John  Bellff  asserts  that  “ when  ha3morrhage  stops  of  its  own  accord,  it  is  j 
neither  from  the  retraction  of  an  artery,  nor  the  constriction  of  its  fibres, 
nor  the  formation  of  clots,  but  by  the  cellular  substance  which  surrounds! 
the  artery  being  injected  with  blood;”  and  he  supposed  the  pressure  thus 
occasioned  to  be  the  cause  of  the  suppression  of  the  bleeding. 

More  extended  observation  has  taught  us  that  each  of  these  means; 
contributes  its  due  share  towards  the  object  which  Nature  has  in  view; 
and  we  now  consider  that  the  flow  is  temporarily  restrained  partly  by  the 


* Mem.  de  1’Acad.  Roy.  des  Sciences. 

f Mem.  de  l’Acad.  Roy.  de  Ghirurg.,  vol.  v.  8vo.  edit.  He  refers  it  to  the  crisping  of  the 
Vessel,  “ crispation  du  tuyau .” 

t Operations  in  Surgery,  2nd  edition,  1739. 

§ Treatise  on  the  Method  of  Suppressing  Heemorrhage  from  divided  Arteries,  1763. 

|]  Cases  in  Surgery,  1770.  Chirurg.  Works,  1766. 

**  Melanges  de  Chirurg.,  1760. 
tt  Principles  of  Surgery,  1826,  vol.  i.  p.  2.50. 


UTERINE  HAEMORRHAGE. 


331 


extremity  of  the  vessel  contracting,  partly  by  its  retraction  within  the 
surrounding  cellular  substance,  partly  by  blood  effused  into  that  cellular 
substance,  and  partly  by  a conical-shaped  clot  formed  at  its  extremity, 
and  passing  to  a considerable  distance  within  its  canal.  But  it  must  be 
evident  that  such  slender  safeguards,  even  when  acting  under  the  most 
favourable  circumstances,  can  only  exert  an  influence  for  a limited  time, 
and  that  there  must  be  great  danger  of  renew’ed  bleeding  on  the  applica- 
tion of  many  trifling  exciting  causes.  Nature,  then,  not  content  with  the 
insufficient  security  obtained  through  these  means,  has  instituted  another 
process,  by  which  the  perviousness  of  the  canal  is  permanently  destroyed. 
The  divided  extremity  of  the  artery  inflames,  its  vasa  propria  pour  out 
lymph,  which,  adhering  to  the  internal  Coat  of  the  vessel,  fills  up  the 
cavity,  and  eventually  obliterates  the  canal.  Its  coats  also  become 
thickened  by  & similar  process — namely,  a deposition  of  lymph  within 
their  structure ; by  which  two  conjoint  actions  the  vessel  is  converted,  in 
process  of  time,  into  a ligamentous  cord ; and  this  ch^fige  is  usually 
observed  to  have  taken  place  as  high  as  the  first  lateral  branch  given  off 
above  the  seat  of  injury. 

It  is  an  established  principle  of  improved  surgery,  in  cases  where  an 
artery  is  pricked,  and  cannot  be  secured  to  divide  it  completely  across ; 
by  which  the  best  chance  is  afforded  it  of  diminishing  its  capacity,  of 
burying  itself  within  the  surrounding  cellular  structure,  and  of  becoming 
plugged  at  its  cut  extremity  by  the  formation  of  a clot. 

From  observing  these  wonderful  expedients  adopted  by  Nature,  and 
the  changes  she  has  instituted,  modern  art  has  derived  a most  valuable 
lesson  ; and  the  surgeon  now  throws  a ligature  around  thfe  sides  of  the 
canal,  which  at  once  renders  it  instantly  impervious,  in  the  same  manner 
that  Nature  attempts  through  the  medium  of  a coagulum  of  blood ; and 
the  process  of  adhesion  and  consolidation  afterwards  advance  in  even  a 
more  rapidly  progressive  manner. 

To  apply  this  to  our  present  purpose,  let  us  examine  if  there  are  any 
means  analogous  to  those  just  described,  by  which  Nature  or  art  can 
restrain  haemorrhage  from  the  uterus  under  labour.  From  the  small 
quantity  of  loose,  cellular  substance  which  that  organ  possesses,  and  the 
peculiar  formation  and  arrangement  of  its  vessels,  we  must  consider  it 
impossible  that  they  should  be  able  to  shorten  and  bury  themselves  within 
the  surrounding  parts;  so  that  we  can  hardly  expect  either  contraction  or 
retraction f\6  assist  us  in  this  emergency.  ' 

I am  not* prepared  to  say  that  coagulation  does  not  occasionally  take 
place  at  the  vascular  apertures  opened  on  the  separation  of  the  placenta ; 
on  the  contrary,  indeed,  I have  had  frequent  proofs  that  it  does,  and  that 


332 


COMPLEX  LABOUR. 


it  is  some  safeguard  against  the  continuance  of  haemorrhage  ;*  but  still  it 
is  a very  poor  one,  and  one  upon  which  we  are  not  warranted  in  relying, 
provided  there  are  any  other  means  which  we  can  ourselves  put  in  prac- 
tice. Nor  am  I exactly  prepared  to  say  that  consolidation  of  the  vessels 
by  coagulating  lymph  might  not  perhaps  occur;  but  we  should  not  d 
priori  expect  it,  because  the  occasion  of  its  deposition,  in  a divided  vessel, 
is  the  inflammatory  state  set  up  as  a consequence  of  injury.  In  the  sepa- 
ration of  the  placenta  from  its  uterine  attachment,  however,  there  is  no 
solution  of  the  continuity  of  the  vessel  itself — there  is  no  injury  sustained! 
by  it — and  we  cannot,  therefore,  with  any  show  of  reason,  anticipate  the 
occurrence  of  adhesive  inflammation.  But  even  presuming  that  it  was! 
possible  for  a consolidation  of  the  bleeding  vessel  to  occur  to  the  fullest! 
extent,  still  the  process  must  occupy  a considerable  time;  Nature  cannot 
effect  it  at  once; — in  hasmorrhage  under  labour,  death  must  occur  before 
even  it  could  be  commenced  ; consequently  it  cannot  be  considered  as  a 
means  of  preservation. 

But  independently  of  the  formation  of  coagula — independently,  if  it  were; 
even  possible,  of  the  consolidation  of  the  trunk  of  the  vessels,  and  their! 
retraction — Nature  arrests  uterine  haemorrhage  under  labour  by  means; 
as  sure,  as  powerful,  as  effective,  nay,  even  more  so  than  the  silken  liga- 
ture of  the  surgeon,  and  almost  analogous  to  it: — namely,  by  the  con-" 
traction  of  the  uterine  fibres.  The  blood-vessels  have  been  described  as 
circulating  through  the  uterus  in  a most  tortuous  manner,  intersected  and 
surrounded  by  the  uterine  fibres  in  the  form  of  a complicated  net- work. 
When  the  fibres  of  the  uterus  contract,  the  vessels  are  closed  by  the  com-i 
pression ; and  it  is  to  this  admirable  contrivance,  to  this  incomparable! 
system  of  “ living  ligatures,1 ” that  all  women  owe  their  safety  after  deli-' 
very.  This  arrangement  of  Nature  possesses  a decided  advantage  over 
the  art  of  the  surgeon ; because  not  only  is  the  trunk  of  the  vessel  closed 
at  one  point,  of  a line’s  breadth,  but  the  compression  extends  along  the 
the  whole  of  its  canal.  We  must  ever  bear  in  mind,  that  it  is  to  uterine 
contraction  alone  we  are  to  look  for  the  ultimate  safet}^  of  every  woman 
from  flooding,  after  the  child’s  birth:  if  it  were  not  for  this  contraction 
she  must  inevitably  die. 

Symptoms. — The  symptoms  which  accompany  uterine  haemorrhage' 
under  labour,  are  those  of  bleeding  in  general.  The  pulse  becomes  quick, 
small,  feeble,  indistinct,  and  fluttering;  the  breathing  becomes  hurried  and 
laboured;  the  respiration  is  drawn  with  sobs  and  sighs;  the' voice  falters; 

* The  excess  of  lymph  that  exists  in  the  blood  of  a pregnant  woman  no  doubt  tends  to 
favour  coagulation. 


UTERINE  HEMORRHAGE. 


333 


the  countenance  is  pallid  ; the  lips  exsanguined ; the  eyes  glassy  and 
lustreless ; the  extremities  cold ; and  a cold  perspiration  breaks  out  on  the 
neck,  face,  and  forehead.  The  pulse,  by  degrees,  becomes  more  feeble 
and  indistinct,  and  at  last  fainting  supervenes.  During  the  continuance 
of  this  faint,  the  patient  remains  motionless,  and  the  pulse  at  the  wrist  is 
not  to  be  felt  at  all  perhaps,  or  at  the  most  is  beating  very  languidly. 
The  heart’s  action  is  also  enfeebled,  or  possibly  suspended  for  a few 
strokes.  After  an  uncertain  time,  the  pulse  is  again  to  be  felt;  the  breath- 
ing is  more  natural;  the  lips  and  cheeks  partially  regain  their  beauteous 
tinge,  and  the  eye  a portion  of  its  fire;  the  extremities  and  the  general 
surface  become  warmer.  With  a return  of  animation — with  a restora- 
tion of  arterial  action — occurs  a return  of  the  bleeding ; and  the  patient 
rallies,  only  to  contend  wfith  fresh  and  increased  dangers.  Again  the 
pulse  flags ; again  she  sobs  and  sighs ; again  there  appear  the  ghastly  face 
and  sunken  eye  ; again  animation  is  suspended ; and  usually  the  second 
faint  is  more  intense  and  longer  than  before.  She  may  recover  a second 
or  a third  time,  with  depressed  powers;  and  now  possibly  restlessness  will 
take  the  place  of  quiet.  At  first  she  throws  her  arms  about,  tosses  off  the 
bed-clothes,  cries  out  for  fresh  air ; and  then  universal  jactitation  super- 
venes. No  entreaties,  and  scarcely  force,  can  restrain  her  in  one  posi- 
tion, till  again  she  sinks  motionless  and  faint.  On  recovering  after  two 
or  three  attacks  of  fainting,  there  will  probably  be  rigours  throughout  the 
whole  frame ; vomiting  may  come  on  : there  is  great  anxiety  of  counte- 
nance and  mind ; — she  is  sure  she  is  dying,  calls  for  her  husband  and 
children ; and  although  her  fortitude  seldom  forsakes  her,  still  much  dread 
and  solicitude  are  evident.  A sense  of  constriction  of  the  chest  will  then 
appear,  as  if  a cord  were  tightly  drawn  around  the  centre  of  the  body. 
This  suffocating  sensation  is  usually  followed  by  two  or  three  convulsions, 
and  death  closes  the  terrible  and  agonizing  scene. 

Although  these  are  the  general  symptoms,  and  they  mostly  occur  in 
the  order  in  which  I have  enumerated  them,  it  is  not  necessary  that  they 
should  all  show  themselves ;— rigours  and  vomiting,  for  instance,  may  be 
wanting ; and  the  time  which  may  be  occupied  from  the  first  commence- 
ment of  fainting  till  death  results,  varies  exceedingly,  according  to  the 
constitutional  strength  and  several  external  circumstances.  Sometimes, 
as  before  remarked,  the  first  attack  of  syncope  carries  off  the  patient”; 
sometimes  there  are  many  faintings ; and  the  vital  spirit  flutters  and" 
hovers  around  the  devoted  head,  as  if  unwilling  to  quit  a tenement  which 
it  has  so  long  inhabited. 

Under  such  a state  of  distress  and  danger,  the  medical  man’s  duty  is 
indeed  of  the  most  arduous  and  harrowing  description ; to  be  of  service, 
he  must  be  prompt,  persevering,  steady,  and  decisive;  and  he  must  con- 


334 


COMPLEX  LABOUR. 


tinue  in  the  use  of  his  means  until  the  total  cessation  of  the  respirator) 
action  proves  that  life  is  entirely  extinct. 

Treatment — In  the  treatment  of  haemorrhage  our  duty  is  two-fold 
first , to  restore  the  patient  from  the  faint  into  which  she  has  fallen,  pro 
vided  its  intensity,  or  the  length  of  its  duration,  indicate  immediate  danger 
secondly , to  prevent  a return  or  increase  of  the  bleeding. 

The  treatment  that  we  should  have  recourse  to  as  a general  principle 
on  flooding  occurring  during  labour,  is  much  the  same  as  that  we  shoulc 
employ  under  many  of  the  ordinary  states  of  haemorrhage.  There  are 
particular  means,  indeed,  which  are  applicable  to  every  particular  case 
and  which  I shall  hereafter  mention,  when  I come  to  treat  of  these  cases 
individually ; but  I shall  now  speak  of  our  management  generally ; and,  ir 
the  first  place,  let  us  give  our  attention  to  venesection.  It  was  formed) 
the  practice  to  consider  that  all  hsemorrhages,  except  they  arose  fronr 
accident,  were  to  be  regarded  as  of  an  active  character;  and,  under  this 
impression,  venesection  was  had  recourse  to,  even  in  flooding  undei 
labour,  with  a view  of  putting  a stop  to  the  discharge.  I have  alread) 
observed,  that  we  look  upon  it  as  a passive  hsemorrhage ; that  it  is  not 
produced  by  the  increased  action  of  the  heart,  causing  a rupture  of  the 
vascular  coats,  but  is  occasioned  by  the  blood  being  allowed  to  exude 
through  orifices  already  rendered  patulous ; and  it  must  be  likened  in  its 
character  to  the  bleeding  from  a punctured  wound.  If  a patient  were 
brought  to  a surgeon  writh  the  radial  or  ulnar  artery,  or  any  other  large 
vessel,  divided,  would  any  man  in  his  senses  think  to  stop  the  flow  ol 
blood  by  syncope  induced  by  bleeding  at  the  arm  ? — Certainly  not ; he 
would  put  a ligature  around  the  vessel,  and  endeavour  to  save  the  patient 
from  a greater  loss:  In  a case  of  placental  presentation,  however,  before 
any  means  were  taken  to  accomplish  delivery,  I have  known  the  lance* 
used,  in  the  hope  of  restraining  the  haemorrhage,  which  very  act, 
great  degree,  diminished  the  woman’s  previous  chance  of  life.*  I d( 
mean  to  assert  that  in  very  many  cases  of  haemorrhage  under  pregna 
and  especially  the  early  stages,  bleeding  may  not  be  highly  useful ; b 
labours  complicated  with  flooding,  it  is  scarcely  ever— nay,  I woulc 
never  serviceable.  The  cautious  surgeon  would  rarely  indeed  pra 
bleeding  from  the  arm  while  the  blood  is  gushing  from  the  uterus  di 
labour. 

Secondly , we  will  consider  the  propriety  of  exhibiting  -opium.  Oj 
is  held  up  by  many  very  great  authorities  as  a most  valuable  mean 

* For  cases  of  placental  presentation  in  which  the  lancet  was  used,  see  Portal’s  Pre^  ice 
Obs.  41  and  79;  also  Smellie’s  cases,  collect.  33,  No.  2,  cases  13  and  14.  Stewai. 
Uterine  Hsemorrhage,  p.  48)  recommends  bleeding  if  the  patient  be  plethoric,  and  not  < 
time. 


UTERINE  HAEMORRHAGE. 


335 


arresting  haemorrhage,  particularly  after  the^child  is  born,  and  the  pla- 
centa has  been  expelled.  Opium  takes  off  muscular  contraction,  by  de- 
stroying nervous  sensibility ; and  it  also  removes  uterine  action — the  very 
power  on  which  alone  we  are  to  rely  for  the  full  and  complete  closure  of 
the  open  vessels.  Does  it  not,  then,  seem  preposterous  to  use  those  very 
means  for  subduing  haemorrhage,  which  would  take  away  our  only  source 
of  safety? — Few  men,  even  its  most  strenuous  advocates,  recommend  it 
at  the  commencement  of  labour,  or  before  the  child  is  born ; and  hereafter 
an  opportunity  will  be  afforded  of  canvassing  its  merits  after  the  birth  is 
perfected. 

Thirdly , stimuli.  Stimuli  are  had  recourse  to  for  the  purpose  of  rousing 
the  vital  energies, — to  keep  the  patient  from  sinking  under  the  faintness 
occasioned  by  the  discharge;  but  their  use  is  dangerous,  and  they  should 
be  avoided,  if  they  can  in  any  way  be  dispensed  with ; because,  under 
their  operation,  the  nervous  and  arterial  systems  are  excited  and  wound 
up  to  a pitch  beyond  the  healthy  standard.  Thus,  as  arterial  action  is 
increased,  the  coagulum  at  the  orifices  of  the  vessels,  if  it  have  been 
formed  at  all,  will  most  likely  become  dislodged.  This  plug  is  to  some  ex- 
tent a safeguard,  but  not  one  to  be  depended  upon,  to  the  exclusion  of  other 
means.  It  is  right,  however,  to  preserve  it  as  long  as  it  answers  the  pur- 
pose of  restraining  the  discharge  in  any  considerable  degree.  Another 
reason  why  we  should  not  unnecessarily  have  recourse  to  stimuli  is,  be- 
cause it  has  now  become  a well-established  physiological  doctrine,*  that 
the  blood  coagulates  more  readily  under  fainting,  than  when  the  cir- 
culating system  is  in  full  vigour.  This  is  a singular  and  most  beautiful  pro- 
vision of  Nature  to  sustain  endangered  life : if,  then,  we  remove  the  faint- 
ing by  suddenly  increasing  the  arterial  powers,  we  prevent  the  deposition 
of  coagula,  as  well  as  run  the  risk  of  forcing  away  the  plug,  even  when 
once  formed.  Cases,  however,  are  unfortunately  occasionally  met  with, 
in  which  we  must  have  recourse  to  stimuli ; — where  we  must  rouse  the 
patient  from  the  faint  into  which  she  has  fallen,  lest  that  particular  syn- 
bope  should  prove  fatal.  We  have  only  the  selection  of  two  evils  offered 
us ; and  we  must  resort  to  stimuli,  as  a matter  of  necessity,  though  not 
of  choice.  These  means,  therefore,  are  never  to  be  employed,  except 
where  danger  is  immediate  and  imminent. 

Fourthly . — Other  remedial  agents  have  been  used  besides  stimuli.  The 
ergot  of  rye  has  been  much  extolled  for  preventing  haemorrhage ; and 
various  papers  have  appeared  from  the  pens  of  well-informed  and  unpre- 
judiced men,f  intended  to  prove  that  it  will  restrain  the  flow  of  blood  from 


* See  Kirkland,  Ilevvson,  Jones,  Thackrah,  &c. 
t See  the  papers  by  Negri,  Medical  Gazette,  vol.  xiii.  p.  3G1,  et  seq. 

* 


336 


COMPLEX  LABOUR. 


other  parts  of  the  body  as  well  as  the  uterine  organ.  Sufficient  trials  hav 
not  yet  been  made  to  enable  me  to  speak  positively  on  the  subject,  wit] 
regard  to  other  organs  of  the  body,  but  it  certainly  has  the  power  of  re 
straining  bleeding  from  the  womb  in  many  varieties.  Where  the  uterin 
fibres  are  too  relaxed  to  produce  the  contraction  requisite  for  the  perfec 
closure  of  the  vessels,  we  shall  find  the  ergot  of  rye  a most  valuable  medi 
cine, — much  more  so,  indeed  than  opium,  whose  action  is  to  remove 
rather  than  excite,  uterine  contraction.  The  ergot  is  particularly  bene 
ficial  in  heemorrhages  preceding  the  birth  of  the  child,  and  in  those  afte 
the  entire  evacuation  of  the  uterine  cavity,  when  it  remains  in  a state  o 
flaccidity, — when  the  fibres,  for  want  of  sufficient  tone,  refuse  to  take  upoi 
themselves  that  contraction  which  is  indispensable  to  the  well-doing  o 
the  patient. 

Fifthly. — Refrigerant  medicines,  and  particularly  the  mineral  acids,  ar« 
very  largely  used  under  uterine  bleeding,  as  well  during  labour  as  in  th< 
unimpregnated  state.  Mineral.acids  it  is  well  known,  coagulate  albumen 
and  direct  experiments,  as  well  as  observations  made  on  patients  affecte< 
with  calculous  disorders,  prove  that  they  are  beyond  the  influence  of  th' 
digestive  powers,  and  enter  the  blood  unchanged.  It  is  reasonable  to  in 
fer,  then,  that  they  may,  in  no  slight  degree,  favour  coagulation,  and  t< 
this  quality  we  may  attribute  their  efficacy  in  most  passive  haemorrhaged 
In  their  power  of  repressing  the  more  violent  discharges,  indeed,  I hav' 
but  little  faith,  and  would  certainly  not  trust  solely  to  their  agency  U 
restrain  any  copious  eruption  of  blood  from  the  uterus  of  a parturien 
woman : but,  as  they  are  generally  grateful  to  the  patient,  and  within  pro 
per  moderation  not  likely  to  prove  injurious,  no  objection  that  I am  ac 
quainted  with  can  be  urged  against  their  use; — provided  too  much  reliance 
be  not  placed  upon  them,  to  the  exclusion  of  other  more  efficient  means 
The  acetate  of  lead  and  alum  have  each  of  them  been  much  extolled  also' 
and  although  they  may  be  occasionally  had  recourse  to  in  uterine  haemor 
rhage  from  other  causes,  they  are,  in  my  opinion,  inappropriate  remedies 
in  those  cases  of  the  more  copious  floodings  which  we  sometimes  meet 
with  under  labour. 

Sixthly. — Cold  is  also  a valuable  agent,  when  applied  generally,  to  over- 
come faintness,  and  topically,  for  the  purpose  both  of  moderating  the  flow 
of  blood  to  the  uterine  vessels,  and  exciting  contraction  in  the  uterine 
fibres ; and  when  combined  with  astringents,  its  powers  se6m  to  be  aug- 
mented. In  the  commencement  of  the  flow,  before  faintness  supervenes, 
cold  may  be  resorted  to  almost  universally,  and  without  restraint;  but  its' 
advantage,  when  the  system  is  much  depressed,  is  more  than  equivocal:! 
for  there  is  a point  beyond  which  the  vital  energies  cannot  bear  up  against 
the  continued  application  of  cold  ; and  a khat  point  it  becomes  actually 


UTERINE  HAEMORRHAGE.  337 

injurious.  Some  discrimination  is  therefore  necessary  in  the  use  of  this 
common  and  effective  agent. 

Seventhly. — Pressure  on  the  uterine  tumour  by  a bandage,  or  what  is 
better,  by  the  grasp  of  the  hand,  is  another  means  of  restraining  some 
varieties  of  flooding,  most  powerful,  daily  had  recourse  to,  very  generally 
employed,  and  open  to  few  or  no  objections.  And  the  evacuating  the 
uterus  artificially  is  sometimes  necessary,  though  never  to  be  undertaken 
without  grave  occasion. 

Eighthly. — We  have  been  recommended,  and  especially  by  Leroux,* 
to  plug  the  vagina  in  all  cases  of  ha3morrhage  under  labour;  but  this  prac- 
tice appears  to  me — except  perhaps  under  placental  presentation — likely 
to  be  fraught  with  hazard ; for  the  uterus,  at  the  full  period  of  pregnancy, 
by  reason  of  its  lax  condition,  allows  itself  to  be  easily  distended  with 
coagula;  and — while  its  cavity  is  sufficiently  capacious  to  contain  a large 
quantity — the  source  of  danger  is  concealed  by  the  blood  being  pent  up 
within ; as,  therefore,  the  nature  of  the  case  may  thus  be  overlooked, 
the  peril  is  likely  to  be  increased.  In  haemorrhages  under  abortion, 
indeed,  when  the  cavity  of  the  womb  is  small,  and  its  parietes  inca- 
pable of  distention  to  any  great  extent,  the  tampon  will  often  be  found 
invaluable. 

Ninthly. — Puncturing  the  membranes,  and  letting  off  the  liquor  amnii, 
is  often  resorted  to  in  accidental  haemorrhage  with  the  most  beneficial 
effects;  but  this  subject  requires  a deeper  consideration  than  this  sum- 
mary sketch  will  admit  of,  and  will  be  considered  more  at  length  subse- 
quently. 

Tenthly. — The  plan  of  transfusing  blood  from  the  system  of  another 
person  to  that  of  the  patient,  for  the  purpose  of  rousing  the  dormant 
powers  and  of  sustaining  life  under  haemorrhage,  has  lately  been  practised 
in  some  few  cases  with  success.  Dr.  Blundell  has  given  us  proof  that 
inferior  animals  can  be  nourished  for  a length  of  time  merely  by  injecting, 
at  proper  intervals,  into  their  veins,  the  healthy  blood  of  an  individual  of 
the  same  species : for  he  preserved  a dog  alive  for  three  weeks  in  this 
manner  without  food,  merely  allowing  it  a little  water ; and  in  that  space 
the  animal  was  reduced  but  little  more  than  one-fourth  of  its  whole 
weightf  From  this  experiment  we  may  conclude,  that  the  same  treat- 
ment might  possibly  be  found  efficacious  in  the  human  subject.  As  a 
means  of  preserving  life  after  large  losses  of  blood,  then  transfusion  pro- 
mises to  be  in  some  cases  highly  useful ; and  under  uterine  flooding  during 
parturition,  we  shall  find  that  its  employment  is  more  likely  to  be  benefi. 


* Sur  lcs  Perles  de  Sang.,  p.  270,  &c. 
43 


t Physiological  Researches,  p.  75. 


338 


COMPLEX  LABOURS. 


cial  when  the  organ  is  entirely  empty  and  contracted,  than  at  any  other 
period  of  the  labour.  In  all  cases  of  haemorrhage  perfect  quietude  both  of 
body  and  mind,  and  the  horizontal  posture,  are  essential  to  the  well-being 
of  the  patient. 

Hemorrhage  may  occur  at  any  stage  of  the  labour;  before  the  liquor 
amnii  is  evacuated ; after  the  membranes  have  ruptured,  and  before  the 
head  is  born ; after  the  head  is  born,  while  the  shoulders  are  in  the  pelvis; 
between  the  birth  of  the  child  and  the  expulsion  of  the  placenta ; and  even 
after  the  placenta  is  expelled,  when  the  uterus  is  emptied  of  its  previous 
contents,  and  when,  in  the  common  acceptation  of  the  term,  we  should 
consider  the  labour  as  concluded. 

Haemorrhage  previous  to  the  birth  of  the  child, — To  our  countryman, 
the  late  Dr.  Rigby,* * * §  we  are  indebted  for  a great  practical  improvement 
in  the  treatment  of  flooding  at  the  commencement  of  labour.  He  distin- 
guished haemorrhage,  occurring  previously  to  the  birth  of  the  child,  into 
two  species — the  first  of  which  he  called  unavoidable , and  the  second 
accidental. 

By  the  first  kind — unavoidable — we  understand  cases  in  which  the 
placenta  offers  itself  at  the  os  uteri,  either  blocking  up  the  mouth  of  the 
organ,  or  being  partially  implanted  over  it;  so  that  dilatation  cannot 
take  place,  without  necessarily  separating  the  placenta  more  or  less 
from  its  uterine  attachment,  and  without  rendering  patulous  those  orifices 
which  were  previously  covered  and  closed  by  the  apposition  of  the  mass. 

By  accidental  haemorrhage,  we  mean  those  cases  where  the  placenta — 
being  attached,  not  over  the  os  uteri  or  near  it,  but  in  its  more  natural 
situation,  the  fundus  or  body — becomes,  to  a greater  or  less  extent,  dis- 
united from  the  uterine  surface;  but  where  the  separation  is  perfectly  ac- 
cidental, and  where  it  is  not  necessary  that  bleeding  should  occur  upon  the, 
opening  of  the  os  uteri. 


a.  UNAVOIDABLE  HAEMORRHAGE. 


Placental  presentations — It  has  for  a long  time  been  known  that  the 
placenta  may  be  found  at  the  os  uteri  under  labour  ; and  this  malposition  was 
noticed  by  Guillemeau,f  Mauriceau,J  Amand,§  Astruc,||  Dionis,^[  in  France; 

* Treatise  on  Uterine  Hemorrhage. 

t CEuvres  Completes,  &c.,  fol.  edit.,  p.  319. 

t Traite  des  Maladies  de  Femmes  Grosses,  livre  2,  chap.  27. 

§ Pratique  des  Accouch.,  Obs.  20.  ||  Art  of  Mid.,  1767,  p.  135,  trans. 

H Treat,  on  Mid.,  trans.,  ch,  24. 


PLACENTAL  PRESENTATION. 


339 


Daventer*  in  Holland ; Brackenf  and  PughJ  in  this  country,  besides 
others;  but  they  all  held  the  opinion,  that  it  was  not  originally  apposed  to 
this  part  of  the  uterus  by  nature,  but  that,  in  consequence  of  some  peculiar  ac- 
cidental circumstances,  it  had  become  loosened  from  its  attachment  above, 
had  fallen  down  by  its  own  weight,  and  had  thus  accidentally  placed  itself 
over  the  uterine  orifice.  But,  inasmuch  as  not  only  is  the  placenta 
attached  to  the  surface  of  the  uterus,  but  the  chorion  is  in  apposition  to 
that  surface  throughout  the  whole  extent  of  the  membrane — the  decidua, 
indeed,  being  interposed — and  inasmuch  as  the  membranes  are  closely 
united  with  the  placenta,  it  would  follow  (provided  this  idea  was  correct) 
either  that  they  must  be  torn  from  the  placenta  all  around,  or  that  the 
whole  ovum  should  partially  revolve.  We  know  that  neither  of  these 
occurrences  takes  place ; and  that  there  is  exactly  the  same  arrangement 
of  the  vessels  of  the  cervix  uteri,  and  exactly  the  same  kind  of  connexion 
between  those  vessels  and  the  placenta,  as  obtains  between  that  organ 
and  the  vessels  of  the  other  parts  of  the  uterus,  wrhen  it  is  placed  in  a more 
natural  and  favourable  situation.^ 

Giffard,||  Levret,1T  and  Smellie,**  were  among  the  first  writers  who 
asserted  that  the  placenta  might  be  placed  by  nature  over  the  os  uteri  at 
its  first  formation ; and  the  remark  has  been  perfectly  borne  out  by  the 
observation  of  every  practical  man  since  their  time. 

Under  a placental  presentation,  then,  there  must  necessarily  be  a greater 
or  less  discharge  of  blood,  on  the  dilatation  of  the  os  uteri;  and,  if  the  case 
were  left  entirely  to  nature,  the  bleeding  would  proceed  either  as  a drain- 
ing or  in  gushes,  until  the  successive  faintings  terminated  in  a mortal 
syncope : or — the  os  uteri  dilating  rapidly,  and  the  womb  acting  vigor- 
ously— the  head  of  the  child  bearing  forcibly  against  the  placental  mass, 
might  expel  it  first,  and  itself  quickly  follow : for  it  would  be  impossible 

* Art  of  Mid.,  trans.,  1728,  p.  153.  t Treat,  on  Mid.,  1751,  p.  132. 

* Treatise  on  Mid.,  1754,  p.  112.  § See  Lond.  Med.  Gaz.,  Dec , 1840,  p.  4G2. 

II  Cases  by  Hody,  1734,  pp.  278,  280,  513.  Giffard  seems  to  have  arrived  at  a correct 
/knowledge  of  this  position  of  the  placenta  by  practice  and  personal  observation;  for  in  1729, 
* (case  84,)  giving  the  history  of  a case  of  hemorrhage  before  delivery,  he  says,  « No  part  of 
the  placenta  had  as  yet  sunk  down  [to  the  mouth  of  the  womb]  as  is  customary  upon  flood* 
ing;”  while  in  1730  (case  115)  he  makes  the  following  observation — “I  cannot  implicitly 
accord  to  the  opinion  of  most  writers,  which  is,  that  the  placenta  always  adheres  to  the  fundus 
uteri ; for,  in  this  'as  well  as  many  former  instances,  I have  good  reason  to  believe  that  it 
sometimes  adheres  to,  or  near,  the  os  internum,  and  that  the  opening  of  it  occasions  a sepa- 
ration, and  consequently  a flooding.  See  for  the  same  opinion  his  next  case,  116.  Heister 
(Institut,  Chirurg.,  chap.  1 54,  parag.  1,)  says  some  of  the  moderns  consider  as  a cause  of 
hemorrhage,  the  adhesion  of  the  placenta  to  the  mouth  of  the  womb  ; so  that  the  more  the 
os  uteri  is  dilated,  the  greater  is  the  separation  of  the  placenta,  and  the  more  profuse  the  flood- 
ing— This  work  was  written  in  1739. 

If  L’Art  des  Accouch.,  1761,  p.  343.  **  Treat,  on  Mid.,  1779,  p.  143. 


340 


COMPLEX  LABOURS. 


for  the  child  to  perforate  the  placenta,  and  pass  through  it;  and  it  would 
also  be  unlikely  that  it  should  escape  by  its  side,  provided  the  mass  were 
implanted  centrally  over  the  uterine  mouth.  A number  of  cases  are  on 
record  in  which  the  placenta  was  expelled  before  the  child,  in  the  manner 
I have  just  mentioned.  Smellie  has  noted  three,* * * §  La  Motte  three, j*  Lee 
three ;{  my  father§  has  given  three  which  came  under  his  own  observa- 
tion; and  two  others  communicated  to  him  by  friends.  Baudelocque,|| 
Perfect,^!  Merriman,**  Barlow, ft  and  Collins, JJ  each  mention  a case. 
Hamilton  had  seen  two,§§  I have  met  with  two,  and  others  are  scattered 
through  the  various  periodicals.  Although  there  is  thus  a possibility  of  a 
natural  termination  of  the  labour  by  the  placenta  passing  first,  and  the 
child  being  expelled  afterwards,  it  would  be  w’rong  to  expect  it,  or  to  wait 
for  it ; for  the  probability  is,  that  the  woman  will  bleed  to  death  before  the 
os  uteri  acquires  a diameter  sufficient  to  allow  the  passage  of  the  child’s 
head  through  it. 

Knowing,  then,  that  in  the  great  majority  of  instances  the  patient  will 
die  if  relief  be  not  afforded,  it  is  considered  as  an  obstetric  principle,  that, 
under  entire  placental  presentations,  delivery  should  be  effected  by  art  as 
early  as  is  practicable,  without  incurring  the  risk  of  injury.  I shall  pro- 
ceed, therefore,  to  discuss  the  symptoms,  and  the  mode  of  treatment. 

Symptoms. — There  are  some  symptoms,  which  are  very  suspicious,  of 
placental  presentations,  and  others  that  assure  us  of  the  nature  of  the  case. 
Those  which  are  suspicious  appear  at  the  commencement  of  labour,  and 
even  before  the  accession  of  uterine  action, — during  the  last  weeks  of 
pregnancy. 

We  have  already  learned,  that  in  the  first  few  months  of  utero-gesta- 
tion,  until,  indeed,  between  the  fifth  and  sixth,  the  cervix  uteri  is  not  de- 
veloped ; it  has  not  yet  been  expanded,  or  taken  up  to  form  a portioi 
the  general  cavity ; but  when  five  months  are  perfected,  or  about  that 
riod,  expansion  commences,  and  this  unfolding  or  developing  of  the  fil 
must  necessarily  produce  a separation  of  the  placenta  from  its  prev; 
attachment  to  the  upper  part  of  the  cervix.  This  separation  must  in 
turn  occasion  flooding,  even  before  the  process  of  labour  is  begun ; bec£ 
the  orifices  of  the  vessels  previously  plugged  by  the  placental  mass 
opened  on  its  partial  dislodgment  by  the  gradual  expansion  of  the  ute 

* Collection  18,  No.  3,  Cases  5,  6,  7.  ‘ . . ’ 

t Traite  des  Accouchemens,  1765,  Obs.  321,  322,  323. 

X Medical  Gazette,  July  13th,  1839. 

§ Practical  Observations,  case  154,  and  two  following. 

|j  Vol.  ii.  p.  37,  translation.  ^ Case  109.  **  Page  121. 

tt  Essays,  p.  273.  tt  Practical  Observations,  p.  91. 

§§  MS.  Lectures,  1821. 


n.  xiiVii. 


Fif.JJ*. 


L,Miv£RS;vy  of' iuinjojc 


PLACENTAL  PRESENTATION. 


341 


neck.  We  find,  then,  that  during  the  last  few  weeks  of  pregnancy,  a pa- 
tient under  placental  presentation  is  liable  to  sudden  gushes  of  blood,  in  a 
greater  or  less  quantity,  coming  on  without  any  apparent  cause, — neither 
the  consequence  of  exertion,  nor  accident,  nor  mental  agitation ; but  when 
she  is  asleep  in  bed, — while  she  is  sitting  quiet  in  her  chair, — when  unem- 
ployed in  any  active  duties, — she  is  unexpectedly  seized  with  a flow  of 
blood  from  the  vagina.  Her  attention,  perhaps,  is  scarcely  drawn  to  the 
occurrence  before  it  has  subsided,  or  diminished  to  such  a degree  as  to 
give  her  but  little  uneasiness : she  will  probably  suppose  that  labour  is 
coming  on,  and  she  may  begin  to  make  preparations  for  its  approach. 
After  the  lapse  of  a few  days,  another  gush  takes  place  as  unaccountably, 
and  subsides  as  suddenly  as  the  former;  and  attacks  of  the  same  kind 
recur  at  uncertain  intervals  during  the  remainder  of  her  pregnancy. 

Whether  the  patient’s  mind  be  impressed  with  much  alarm  or  not  at 
these  repeated  bleedings,  to  one  acquainted  with  the  physiology  of  the  pla- 
centa, and  the  peculiar  connexion  between  that  organ  and  the  uterus,  such 
a history  would  be  fraught  with  suspicion  and  anxiety ; and  she  should  be 
watched  over  with  the  most  assiduous  and  solicitous  attention. 

Our  suspicions  may  also  be  excited  at  the  beginning  of  labour,  if  with 
every  pain, — with  every  slight  increase  of  dilatation  in  the  os  uteri,  there 
be  an  increase  of  discharge,  and  if  the  flow  of  blood  be  moderated  or  sus- 
pended in  the  interval  of  action. 

But  we  can  only  positively  assure  ourselves  of  the  nature  of  the  case  by 
an  examination  per  vaginam.  To  this  the  patient  may  be  unwilling  to 
submit ; she  may  suppose  we  can  be  of  no  service  to  her,  since  the  pains 
are  so  infrequent  and  trifling.  It  is  our  bounden  duty  to  combat  her  ob- 
jections, and  to  insist  on  the  necessity  of  the  measure  proposed ; since  our 
practice  so  much  depends  on  the  information  we  gain.  The  examination 
will  most  advantageously  be  made  with  the  first  two  fingers  of  the  left 
hand,  because  they  pass  so  much  higher  within  the  pelvic  cavity,  and  so 
much  more  completely  command  the  os  uteri.  By  this  inquiry  we  learn 
whether  the  placenta  be  implanted  over  the  mouth  of  the  womb  or  not ; 
and  if  we  discover  its  presence,  we  must  ascertain  whether  the  orifice  be 
entirely  or  only  partially  occupied  by  its  mass ; for  our  practice  differs 
much  under  the  two  varieties. 

Diagnosis. — We  shall  know  the  placenta  by  the  fleshy,  fibrous,  and 
lobular  sensation’  which  it  communicates  to  the  finger,  and  by  its  being 
attached  to  the  inner  surface  of  the  cervix  uteri.  Plate  XLVII.  fig.  132, 
copied  from  Hunter,  shows  the  placenta  implanted  over  the  uterine  mouth. 
If  we  can  introduce  our  finger  sufficiently  far  to  pass  it  round  within  the 
orifice,  we  shall  be  sensible  of  this  attachment,  although  the  union  is  very 
easily  separated.  There  is  but  little  chance  of  mistaking  the  placenta  for 


342 


COMPLEX  LABOURS. 


the  membranes  partially  protruded  into  the  vagina ; but  there  is  great  pro 
bability  that  we  may  mistake  a coagulum,  blocking  up  the  os  uteri,  foi 
the  placental  mass  apposed  over  it.  How,  then,  shall  we  discriminate  be 
tween  these  two  ? — The  placenta  cannot  easily  be  perforated  or  broker 
down;  the  tenacity  of  a coagulum  may  without  difficulty  be  destroyed 
Ihe  placenta  is  attached  within;  a coagulum  lies  loose.  The  placenta 
cannot  be  removed  by  the  finger ; but  we  can  generally  bring  away  a co- 
agulum. If  there  be  any  doubt,  we  should  take  these  means — we  shoulc 
try  whether  it  is  attached, — whether  we  can  break  down  its  structure 
and  whether  we  can  remove  it  from  its  position ; but  these  attempts  musi 
be  made  with  the  greatest  possible  care.  The  detached  surface  of  the 
placenta  is  in  these  cases  often  covered  by  a smooth  layer  of  firm  coagu- 
lated blood,  which  being  interposed  between  the  finger  and  the  substance 
of  the  mass,  prevents  our  feeling  the  placenta  itself ; and  deception  maj 
thus  arise.*  But  a careful  attempt  to  break  down  the  coagulum,  or  re- 
move it  from  its  situation,  has  always  been  sufficient  to  assure  me  of  the 
true  nature  of  the  case. 

Management  of  placental  presentation. — Since,  when  the  placenta  is 
situated  over  the  mouth  of  the  womb,  attacks  of  haemorrhage  generally 
recur  at  uncertain  intervals  during  the  last  few  weeks  of  pregnancy,  so  it 
is  more  than  probable  that  our  attendance  may  be  desired  on  two  or  three 
occasions  previously  to  the  accession  of  labour;  the  patient  being  suddenly 
seized  with  a gush  of  blood,  while  in  bed  perhaps,  or  otherwise  quiet? 
She  will  very  possibly  suppose  at  first  that  the  membranes  have  broken; 
and  expect  labour  to  follow  rapidly ; but,  on  examining  her  linen,  she 
becomes  sensible  that  the  discharge  is  blood,  and,  in  a greater  or  less 
alarm,  summons  her  medical  attendant  to  her  assistance.  On  his  arrival, 
he  will  probably  find  that  the  flow  has  ceased,  and  that  she  is  more  com- 
posed, though  still  perhaps  a little  faint. 

Our  first  endeavour,  under  such  circumstances,  should  be  to  calm  the 
mental  agitation;  and  the  next,  to  prevent  a return  of  the  bleeding. 
Should  the  flow  have  ceased,  and  not  been  profuse,  we  may  with  truth 
and  propriety  assure  her  that  there  is  no  present  danger,  and  that  the  pre- 
vention of  a recurrence  will  much  depend  on  her  own  conduct;  and  we 
must  proceed  to  lay  down,  in  the  strictest  manner,  rules  'for  her  future 
guidance.  As  a general  principle,  bleeding,  and  the  exhibition  of  digitalis 
or  other  depressing  agents,  are  in  such  a case  inadmissible;  perfectly  so 
indeed,  unless  she  be  plethoric, — unless  the  arterial  system  be  acting  with 
undue  energy,  or  unless  fever  be  present,  or  indications  of  local  determi- 
nation to  some  particular  organ. 


* See  Ingleby  on  Uterine  Haemorrhage,  p.  142. 


PLACENTAL  PRESENTATION. 


343 


Nor  shall  we  find  it  generally  necessary  to  make  a vaginal  examina- 
tion, unless  indeed  the  pains  of  parturition  have  already  shown  them- 
selves ; for  if  the  term  of  pregnancy  be  distant  five  or  six  weeks, — the  os 
uteri  being  closely  shut, — by  such  an  inquiry  we  should  gain  no  informa- 
tion ; we  might  moreover  disturb  the  coagula  formed  at  the  patulous  vas- 
cular orifices ; and  thus  we  should  run  the  risk  of  causing  a renewal  of 
the  bleeding.  However  desirable,  then,  it  might  be  positively  to  ascertain 
whether  the  placenta  were  situated  over  the  os  uteri  or  not, — since  this 
knowledge  is  so  difficult  to  acquire,  and  since  the  attempt  would  most 
likely  augment  the  danger,— it  is  better  that  we  should  remain  satisfied 
with  suspicion,  than  that  we  should  disturb  the  temporary  safeguard 
Nature  has  established ; especially  as  no  means  can  be  used  except  of  a 
palliative  nature,  so  long  as  the  os  uteri  continues  perfectly  closed.  But, 
on  the  other  hand,  if  the  flooding  be  still  going  on, — if  the  patient  have 
arrived  at  the  end  of  gestation,  or  near  it,  and  particularly  if  the  uterus  be 
contracting  at  intervals,  however  weak  the  pains  may  be, — we  should 
insist  on  making  an  examination  per  vaginam,  and  act  according  to  the 
principles  immediately  to  be  laid  down.  I shall  now  presume  that  labour 
has  not  commenced,  that  the  term  of  gestation  is  not  fulfilled,  and  that  the 
discharge  has  entirely  or  nearly  subsided  on  our  arrival. 

Absolute  and  uninterrupted  quietude  in  the  horizontal  posture,  and  on  a 
hard  bed,  must  be  forcibly  enjoined,  and  an  anti-haemorrhagic  regimen 
prescribed;  she  must  breathe  a cold  atmosphere;  be  but  lightly  covered; 
her  diet  must  principally  consist  of  nutritious  fluids— cold  and  acid  drinks 
may  be  given  almost  ad  libitum , and  ices  may  be  allowed,  unless  they 
produce  intestinal  pain  or  shivering : every  thing  stimulating,  both  alco- 
holic or  of  any  other  nature,  must  be  strongly  forbidden.  The  mineral 
acids,  under  such  a case,  may  be  usefully  employed ; some  gentle  aperient 
will  be  required,  and  the  acidulated  infusion  of  roses,  with  small  doses 
of  sulphate  of  magnesia,  is  perhaps  the  pleasantest,  and  at  the  same  time, 
as  efficacious  a medicine,  as  any  that  can  be  exhibited.  We  must  avoid 
a constipated  state  of  bowels;  because  the  straining  necessary  for  the  pas- 
sage of  hardened  faeces  may  dislodge  the  coagula  collected  over  the  ex- 
posed vessels,  and  produce  a return  of  the  flooding.  We  must  equally, 
also,  avoid  violent  purging,  lest  the  frequent  evacuation  of  the  rectum 
should  occasion  a like  disaster.  A cold  enema  may  be  administered  daily, 
which  will  pVobably  act  beneficially  in  two  ways, — both  by  clearing  the 
rectum,  and  restraining  the  haemorrhagic  tendency.  Opium  may  be  exhi- 
bited if  there  be  present  much  nervous  irritabilty,  an  excited  state  of  mind, 
or  spasmodic  and  false  pains ; but  as  I have  little  faith  in  the  power  of 
opium  to  suppress  haemorrhage,  I should  not  administer  it  with  that  spe- 
cific intention ; and  I think  I have  obtained  as  much  advantage  from  the 


344 


COMPLEX  LABOURS. 


pharmacopoeial  preparations  of  henbane  or  hemlock,  in  quieting  an  excite 
state  of  the  nervous  system  under  these  circumstances,  as  from  opiur 
itself.  Before  our  departure,  we  must  direct  that,  on  the  occasion  of  anc 
ther  attack,  cloths  steeped  in  vinegar  and  water  should  be  applied  to  th 
vulva  and  lower  part  of  the  abdomen,  and  that  we  should  instantly  b 
made  acquainted  with  the  occurrence.  It  is  very  possible  that  we  may  b 
called  three  or  four  times  to  the  same  patient  under  the  same  circurr 
stances,  and  on  each  occasion  may  think  right  to  repeat  the  same  caution 
and  general  directions. 

But  a period  will  arrive  when  the  features  of  the  case  will  be  changed 
when  uterine  action  will  supervene,  and  when  the  mouth  of  the  womb  wi 
begin  to  dilate,  and  the  haemorrhage  will  consequently  be  increased.  ! 
then  becomes  our  duty  carefully  to  consider  when  delivery  shall  b 
effected,  under  the  conviction  that  it  will  be  ultimately  necessary,  and  th£ 
our  patient  will  remain  in  imminent  danger  until  it  is  accomplished. 

In  determining  this  question,  it  must  be  evident  that  until  a certain  dt 
gree  of  dilatation  is  effected,  the  hand  cannot  be  introduced  to  accomplis 
the  proposed  end ; but  it  is  also  evident  that  if  we  wait  until  the  os  ute 
is  widely  open,  the  probability  is,  that  the  patient  will  be  so  exhausted  s 
to  leave  little  chance  of  her  survival,  even  under  the  most  skilful  manage 
ment.  The  two  extremes,  therefore,  of  forcing  the  hand  through  th 
mouth  of  the  womb,  while  it  will  not  admit  of  artificial  dilatation  withoi 
sustaining  injury,  and  of  delaying  our  means  until  the  system  is  depressed 
beyond  the  hope  of  recovery,  are  both  equally  to  be  deprecated  in  prac 
tice;  and  it  becomes  a very  nice  point  to  fix  the  exact  time  when  ou 
assistance  will  be  most  serviceable. 

We  may  lay  it  down  as  an  axiom,  that  as  soon  as  the  os  uteri  is  dilate 
to  the  diameter  of  half  a crown,  the  hand  may  generally  be  introduce; 
without  injury,  provided  the  term  of  gestation  be  fully,  or  nearly  con* 
pleted ; and  that  it  would  be  unwise  to  wait  for  its  farther  developmen; 
because  we  may  expect  that  with  the  increase  of  every  line’s  diametei 
there  will  be  an  increase  of  the  bleeding,  and  that  such  a fearful  loss  will  b 
sustained  as  will  eventually  terminate  in  death.  When  this  specified  de 
gree  of  dilatation  is  acquired,  we  are  warranted  in  undertaking  delivery 
and  it  is  to  be  accomplished  in  the  following  manner.  The-patient,  lyin, 
on  her  left  side,  is  to  be  brought  conveniently  near  the  edge  of  the  bee 
and  gently  restrained  by  the  means  I have  before  mentioned  when  speafc 
ing  of  transverse  presentations.  The  operator  having  taken  off  his  coa 
and  kneeling  by  the  bed-side, — the  left  hand  and  arm  being  greased, — th 
fingers  are  to  be  collected  into  the  form  of  a cone,  slowly  insinuate* 
through  the  external  parts,  and  carried  up  to  the  brim  of  the  pelvis,  in  th 
direction  of  the  axis  of  the  vagina;  with  a slow  semi-rotatory  motion  th 


PLACENTAL  PRESENTATION. 


345 


os  uteri  must  be  carefully  dilated,  and  the  hand  passed  fully  into  the  ute- 
rine cavity, — by  the  side  of  the  placenta, — partially  separating  that  organ 
from  its  attachment  to  the  uterine  neck.  It  must  be  introduced  either 
anteriorly,  posteriorly,  or  laterally,  in  which  ever  direction  the  placenta 
appears  to  be  thinnest,  because  the  edge  of  the  organ  will  then  most  pro- 
bably be  soonest  reached,  and  the  uterine  vessels  will  there  be  found 
smallest.  It  is  not,  however,  always  easy  to  distinguish  the  point  at  which 
the  placental  edge  may  be  arrived  at  most  readily:  in  this  part  of  the  ope- 
ration, then,  we  must  trust  somewhat  to  accident.  Having  gained  the 
membranes,  they  must  be  punctured,  the  hand  carried  into  the  centre  of 
the  ovum,  run  along  the  person  of  the  child  until  the  feet  be  felt ; and  one 
or  both  of  these  limbs  must  then  be  brought  down  through  the  rent  in  the 
foetal  membranes.  The  child’s  body  is  thus  made  to  revolve  on  its  own 
axis, -^-provided  the  head  presents  or  it  lies  transversely, — and  the  breech 
descends  into  the  pelvis.  To  facilitate  the  expulsion,  and  to  ensure  ulti- 
mately as  perfect  a contraction  of  the  uterus  as  possible,  gentle  friction 
may  be  applied  over  the  uterine  tumour,  through  the  parietes  of  the  abdo- 
men ; and  unless  the  haemorrhage  be  continuing  profusely,  rapid  extraction 
of  the  child’s  body  should  be  most  cautiously  avoided. 

When  about  to  perform  the  operation  just  described,  it  must  be  remem- 
bered by  the  practitioner  that  his  patient’s  life  will  depend  in  a great  mea- 
sure on  his  own  knowledge,  presence  of  mind,  and  perseverance;  and 
when  once  he  has  undertaken  the  dilatation  of  the  os  uteri,  he  must  un- 
flinchingly proceed  to  the  termination  of  the  delivery,  unless  some  extra- 
ordinary difficulty  should  present  itself.  The  hand,  then,  must  be  passed 
slowly  and  carefully  onwards ; for  to  withdraw  it  would  be  to  risk  a 
renewal  or  perilous  increase  of  the  bleeding. 

It  might  be  supposed  that  the  extensive  separation  of  the  placenta  from 
its  uterine  attachment,  in  the  introduction  of  the  hand,  as  just  described, 
must  in  all  cases  produce  a frightful  augmentation  of  the  haemorrhage,  and 
that  there  would  be  little  chance  of  the  patient’s  survival.  This,  however, 
fortunately,  is  not  usually  the  case.  On  the  first  introduction  of  the  fin- 
gers through  the  os  uteri,  there  is  certainly  almost  always  a gush  of  blood, 
and  perhaps  to  a copious  extent;  but  when  the  hand  has  fully  entered  the 
orifice,  by  the  pressure  it  exerts  on  the  open  vessels  it  acts  as  a plug,  and 
prevents  any  great,  additional  loss ; as  it  is  carried  farther,  the  arm  per- 
forms the  same  office ; and  when  the  breech  of  the  child  is  brought  into 
the  vagina,  or  to  rest  upon  the  pelvic  brim,  the  body  itself  causes  a like 
compression : so  that  if  the  delivery  be  skilfully  managed,  the  increase  of 
bleeding  which  takes  place  under  it  is  comparatively  trifling. 

Dreading  the  fresh  accession  of  discharge  which  it  was  thought  must 
necessarily  attend  the  uncovering  of  so  many  vascular  orifices,  by  the 
44 


346 


COMPLEX  LABOURS. 


hand  being  slid  between  the  neck  of  the  womb  and  the  placenta  apposed 
over  it,  some  practitioners  have  recommended  that  we  should  perforate  the 
substance  of  the  placenta  itself,  by  working  our  fingers  successively  through 
it  * To  me,  indeed,  this  proceeding  offers  many  objections;  and  the  prin- 
cipal consists  in  the  difficulty  of  its  performance.  It  is  by  no  means  an 
easy  matter  to  perforate  the  structure  of  the  placenta  by  the  fingers,  when 
the  organ  is  taken  out  of  the  body  and  lying  on  a table ; how  much  more 
difficult  must  it  be,  then,  to  run  the  fingers  through  it,  when  it  is  attached 
over  the  os  uteri,  when  there  is  no  resistance  behind,  to  favour  our  attempt! 
How  much  more  likely  is  it  that  the  mass  may  be  lifted  entirely  away 
from  its  connexion  with  the  neck  of  the  womb,  and  carried  up  before  the 
hand  ! And  if  this  should  occur,  it  is  reasonable  to  suppose  that  the  dis- 
charge would  be  much  more  profuse  than  if  a smaller  portion  were  sepa- 
rated, and  the  hand  slid  along  between  it  and  the  open  vessels.  It  cer- 
tainly happens  occasionally  that  the  placenta  is  so  soft  as  scarcely  to  bear 
being  lifted  by  its  edge  without  falling  to  pieces;  and  under  such  a morbid 
state  the  fingers  might  easily  be  passed  through  it ; but  this  is  unusual,  and 
our  practice  must  be  regulated  not  by  the  exceptions,  but  the  general  prin- 
ciple. Besides,  the  aperture  made  in  the  placenta  by  the  hand  not  being 
larger  than  the  hand  itself,  sufficient  space  is  not  gained  to  admit  the  easy 
passage  of  the  child’s  body,  arms,  and  head,  which  must  forcibly  lacerate 
the  mass  as  they  are  being  extracted ; in  such  case,  not  only  must  the 
pressure  on  the  funis  be  great,  but  there  would  be  danger  of  the  placenta 
being  entirely  pulled  away  from  its  connexion  with  the  uterus,  as  the 
arms  were  being  extracted. 

Again,  so  long  as  we  preserve  the  placenta  entire,  we  prevent  any  loss 
of  blood  from  the  foetal  system ; but  when  that  organ  is  torn,  the  vessels# 
must  necessarily  be  ruptured,  and  the  child,  if  it  be  alive,  will  most  pro-1 
bably  bleed  to  death.  It  is  almost  incredible  how  small  a loss  of  blood  is’ 
sufficient  to  destroy  a newly -born  infant.  A few  drachms  oozing  from  the 
funis,  if  the  ligature  be  loosely  tied,  has  been  known  to  cause  a fatal  result 
By  perforating  the  placenta,  then,  we  run  a great  risk  of  destroying  the 
foetus.  It  may  be  argued,  that  the  life  of  the  child  is  not  to  be  brought 
into  competition  with  the  safety  of  the  mother;  nor  indeed  should  it;  but 
as  I believe  there  is  equal,  if  not  more  danger,  incurred  to  the  mother  by' 
such  a mode  of  action,  I would  endeavour  by  all  means  to  preserve  the  : 
child,  provided  that  were  possible.  It  may  be  said  moreover  that  in  many 

* According  to  Richter,  this  practice  was  first  introduced  by  De  Leurie  and  Mohrenheim,  j 
(Praxis  Medico-Obstetricise  Mosquce,  1810,  4to.  p.  176.)  Smellie,  however,  (case  8,  No-.  2, 
collect.  33,)  states  that  not  being  able  to  perforate  the  membranes,  he  pushed  his  fingers  through  ; 
the  placenta.  In  case  14,  related  to  him  by  a professional  friend,  the  placenta  was  also  per- f 
forated. 

* 


PLACENTAL  PRESENTATION. 


347 


cases  of  placental  presentation, — if  not  the  majority, — the  child  is  born 
still ; and  that  therefore  the  chance  of  its  ultimate  survival  is  but  small. 
This  I am  willing  to  grant  also ; but  if  the  fcetal  vessels  be  preserved  entire, 
Us  death  is  caused,  not  by  any  loss  of  blood  from  the  fcetal  system  itself, 
but  in  consequence  of  its  being  deprived  of  the  benefits  which  result  from 
the  uterine  circulation.  During  the  faint  under  which  the  mother  lies,  the 
blood  is  neither  sent  in  the  same  quantity,  nor  with  the  same  velocity,  to 
the  uterine  organ,  consequently  the  changes  necessary  for  the  continuance 
of  fcetal  life  cannot  go  on  in  the  placenta ; the  child  ceases  to  exist  in  con- 
sequence of  the  want  of  those  changes;  it  dies  from  asphyxia,— as  per- 
fectly suffocated  as  if  it  were  drowned  after  the  commencement  of  breath- 
ing life.* 

But  the  favourable  time  for  the  performance  of  the  operation  which  I 
have  just  noticed  may  have  slipped  by  before  we  have  an  opportunity  of 
seeing  the  patient;  and  we  may  perhaps  find  her  faint,  and  gasping,  and 
cold ; the  uterus  quite  inactive,  with  its  mouth  widely  open,  and  possessing 
that  degree  of  unresisting  flabbiness  which  to  an  experienced  hand,  is 
indicative  of  the  most  urgent  danger.  Under  this  condition,  delivery 
would  indeed  be  easy,  but  it  would  at  the  same  time  be  followed  by  almost 
certain  death : for  if  we  empty  the  uterus  under  syncope,  or  deep  and  long- 
continued  faintness,  we  cannot  reasonably  suppose  it  will  take  upon  itself 
that  degree  of  active  contraction  necessary  to  close  its  vessels,  and  place 
the  woman  in  safety.  It  would,  then,  be  most  injudicious  to  proceed  at 
once  to  the  operation.  Our  indication  should  rather  be,  to  rouse  the  patient 
from  the  torpid  state  in  which  she  is  lying— to  bring  her  system  up  to  a 
certain  point,  before  we  attempt  to  evacuate  the  womb.  Stimulants  here, 
then,  are  absolutely  called  for.  Brandy,  aether,  ammonia,  and  other  cor- 
dials, may  be  exhibited ; and  transfusion  of  blood  might  even  be  performed, 
with  the  view  of  inducing  the  temporary  excitement  so  necessary  to  be 
procured  before  delivery  be  attempted.  To  the  employment  of  opium 
'-under  such  circumstances,  I have  objections,  on  the  grounds  stated  before, 
Although  sanctioned  by  high  authority.  I cannot  agree  with  Professor 
•Hurnsf  and  Dr.  StewartJ  that  this  drug  will  check  the  flow  of  blood ; and 
I think  we  possess  other  cordials  and  stimulants  quite  as  efficacious  in 
rousing  for  a*  time  the  depressed  vital  powers,  by  the  exhibition  of  which 

* I would  refer  the  reader  to  Baudelocque,  parag.  985,  Dewees,  parag.  1152,  and  Davis, 
Ohst.  Med.,  p.  1045,  for  arguments  against  perforating  the  placenta  in  this  case. 

' -t  Fifth  edition,  page  304. 

% 1011  Uterine  Haemorrhage,  p,  49,  he  recommends  four  grains  of  solid  opium,  or  one  hun- 
dred drops  of  laudanum,  to  be  administered  before  proceeding  to  delivery;  that  the  dose  should 
be  repeated  as  often  as  symptoms  of  irritation  occur;  and  increased  according  to  the  urgency 
ofthose  symptoms. 


4 


34S 


COMPLEX  LABOURS. 


we  do  not  incur  the  danger  of  eventually  paralyzing  the  uterine  energies. 
In  most  cases  we  shall  find  the  ergot  a serviceable  remedy  after  the  sti- 
muli have  taken  effect,  and  before  the  operation  is  proceeded  in.  A dose 
or  two  of  this  medicine,  indeed,  may  be  given  in  every  instance  of  pla- 
cental presentation,  previously  to  the  delivery  being  undertaken,  if  time 
admit  of  its  exhibition. 

Under  the  circumstances  now  treated  of  especially  must  we  bear  in 
mind,  that  although  it  is  a maxim  in  obstetric  practice  never  to  allow  a 
woman  to  die  undelivered,  if  delivery  can  by  any  means  be  accomplished, 
still  it  should  also  be  another  maxim,  never  to  empty  the  uterus  during  the 
continuance  of  an  attack  of  syncope;  for  it  is  not  the  mere  extraction  of 
the  child  to  which  our  attention  should  be  directed,  but  leaving  the  patient 
in  the  most  favourable  condition,  with  respect  to  ultimate  recovery,  which 
the  nature  of  the  case  will  admit  of. 

Again,  it  is  by  no  means  impossible  that  such  alarming  symptoms 
may  show  themselves  before  the  os  uteri  has  acquired  the  diameter  of 
half  a crown,  as  to  render  it  extremely  hazardous  for  us  to  delay  our 
means  until  that  degree  of  dilatation  is  arrived  at.  The  blood  may  be 
gushing  forth  in  a copious  and  continued  stream,  or  may  be  oozing  away 
in  a less  violent  though  steady  draining ; or  coagula  of  considerable  size 
may  be  passing  from  the  vagina  every  few  minutes : and  it  must  be  evi- 
dent to  the  least  attentive  observer  that  such  a state  of  things  cannot  be 
allowed  to  proceed  unchecked.  Two  modes  offer  themselves  for  our( 
choice:  either  immediate  delivery,  or  endeavouring  to  restrain  the  flow, 
and  delaying  until  the  due  degree  of  dilatation  is  effected.  Our  practice 
will  mainly  be  guided  by  the  state  of  the  os  uteri  itself : if  it  appear  soft, 
lax,  and  distensible,  offering  but  little  resistance  to  our  fingers  in  the 
attempt  at  dilatation,  we  shall  mostly  be  able,  under  the  use  of  sufii-i 
cient  caution,  to  pass  the  hand  entirely  through  it  without  injury,  evert 
although  its  disc  be  not  exceeding  the  diameter  of  a shilling ; and,  indeed. 
I have  accomplished  the  operation  of  turning  on  some  few  occasions 
under  these  unpromising  circumstances,  by  slowly  insinuating  the  finger* 
seriatim.  Although,  then,  such  a proceeding  be  not  desirable,  if  it  car 
be  avoided, — inasmuch  as  every  minute’s  delay  brings  with  it  an  aug 
mentation  of  danger,-— we  are  fully  justified  in  effecting  the  dilatation  o 
the  os  uteri  thus  artificially,  even  when  at  the  commencement  of  on 
efforts,  it  will  scarcely  admit  the  introduction  of  the  tips  of  the  two  finger:  . 
For,  as  a principle,  we  shall  find  that  delivery  had  better  be  had  recours  j 
to  an  hour  too  soon  than  an  hour  too  late ; and  that  the  frequent  fatalit 
of  these  frightful  cases  is  to  be  attributed,  in  a great  measure,  to  tl  I 
operation  having  been  delayed  until  the  system  was  irrevocably  depresse  ! 
The  dilatability  of  the  organ,  then,  is  to  be  regarded  as  an  indication 


PLACENTAL  PRESENTATION. 


349 


of  its  capability  of  being  fully  opened, — as  much  as,  or  even  more  than, 
its  existing  state  of  actual  dilatation. 

But  the  haemorrhage  may  be  profuse,  and  may  threaten  immediate  dis- 
solution, while  the  os  uteri  is  dilated  to  no  greater  extent  than  the  size  of 
a sixpence  possibly,  and  while  it  remains  in  a rigid,  unyielding  condition ; 
and  this  is  particularly  observable  when  labour  has  commenced  previ- 
ously to  the  full  term  of  gestation  being  completed.  It  is  seldom,  certainly, 
that  flooding  proceeds  to  the  extent  of  endangering  life,  without  also 
causing  a relaxed  state  of  the  uterine  mouth.  But  occasionally  the  com- 
plication of  dangers  just  adverted  to  may  exist  together.  Any  forcible 
attempt 'at  opening  it  artificially  would,  under  such  a state,  be  assuredly 
productive  of  injury,  probably  of  a very  serious  character.  As  delivery, 
then,  could  not  be  accomplished,  except  under  extreme  hazard,  no  alter- 
native is  left  us  but  to  endeavour  to  suspend  the  flow,  and  to  wait  until 
the  mouth  of  the  womb  has  taken  upon  itself  a more  favourable  condition. 
The  common  principles  must  here  be  most  assiduously  followed  ; perfect 
quiet,  in  the  recumbent  posture,  the  application  of  cold,  the  removal  of 
every  cause  of  excitement,  and  the  exhibition  of  cold  and  acidulated 
drinks.  Local  means  may  also  in  some  degree  avail  us ; the  vagina  may 
with  advantage  be  plugged  with  a silk  or  cambric  handkerchief,  or  lint 
steeped  in  oil,  vinegar,  or  a weak  solution  of  alum ; a practice  strongly 
advocated  by  Leroux;* — inadmissible,  however,  in  any  other  case  of 
bleeding  from  the  uterus,  after  four  or  five  months  of  gestation  are  com- 
pleted. Some  practitioners,!’  indeed,  of  great  eminence,  object  to  the 
employment  of  this  means  in  any  case  of  labour  near  the  close  of  preg- 
nancy, fearing  an  internal  accumulation  of  blood,  favoured  by  the  disten- 
sibility  of  the  uterine  parietes ; for,  as  I have  before  insisted,  the  uterus 
at  full  time  is  never  perfectly  filled  by  the  ovum,  but  capable  of  containing 
a considerable  quantity  of  more  matter.  Thus,  then,  although  the  fluid 
be  prevented  draining  through  the  vagina,  much  may  be  collected  within 
the  cavity  of  the  womb,  and  a fatal  termination  may  result.  This  rea- 
soning is  undoubtedly  true,  to  its  fullest  extent,  in  accidental  haemorrhage, 
before  delivery,  under  retention  of  the  placenta,  and  in  floodings  after  the 


* Sur  les  Pcrtes  de  Sang,  p.  238  et  seq. 

t Merriman  (Synopsis,  p.  127)  says  he  thinks  the  plug  inapplicable  in  all  cases  when  the 
bulk  of  the  uterus  exceeds  that  of  a pregnancy  of  three  or  four  months,  or  when  the  parietes 
are  so  easy  of  distention  as  to  yield  readily  to  the  accumulation  within.  Gardien  (Traite 
d’Accouchetnens,  tom.  ii.  p.  419)  objects  to  the  plug  in  placental  presentations,  because  it 
excites  the  uterus  to  dilate  its  orifice,  and  thus  increases  the  haemorrhage.  Stewart,  p.  49, 
makes  the  same  objection  for  the  same  reason.  Hamilton  also  (Pract.  Obs.,  p.  331;  condemns 
it ; while  Davis,  (Obst.  Med.,  p,  1048, ( Burns,  (fifth  edit.,  p.  302,)  and  Pewees  (parag.  1093, 
&c.)  speak  in  favour  of  the  means.  Astringent  injections  in  these  more  formidable  cases  of 
haemorrhage  are  of  no  benefit,  and  they  may  be  injurious  by  washing  away  coagula. 


350 


COMPLEX  LABOURS. 


expulsion  of  that  organ ; nay,  as  the  blood  concretes  in  the  uterine  cavity, 
the  viscus  is  more  and  more  distended ; its  vessels  become  gradually  more 
and  more  dilated : their  orifices  gape  wider  and  wider,  and  consequently 
they  are  rendered  capable  of  pouring  out  a larger  quantity  of  blood  in  a 
given  space  of  time.  Thus,  then,  the  insertion  of  the  plug  would  be 
adding,  in  a geometrically  increasing  ratio,  to  the  peril  of  the  case.  Nor 
must  another  cause  of  additional  hazard  be  overlooked : the  external  flow 
of  blood  being  prevented,  the  source  of  danger  is  concealed,  and  it  is 
possible  for  fatal  deception  to  arise.  But  when  the  placenta  is  implanted 
over  the  os  uteri,  it  is,  in  my  opinion,  unlikely  that  blood  will  be  poured 
out  into  the  womb  itself ; and  if  the  vagina  be  perfectly  filled  with  the 
tampon , there  is  no  other  cavity  in  which  the  vital  fluid  can  collect;  so 
that  I think  we  may  occasionally  have  recourse  to  it  with  advantage. 
Blood  is  certainly  less  likely  to  accumulate  at  the  cervix  uteri  than 
towards  the  upper  part  of  the  organ ; and  such  a collection  near  the  orifice 
as  to  endanger  life  can  only,  in  my  judgment,  occur  under  a state  of 
great  laxity  of  uterine  fibre,  and  extreme  depression  of  the  vital  energies. 

Another  objection  which  has  been  raised  to  the  use  of  the  plug  in  these 
cases,  consists  in  the  necessity  of  removing  it  whenever  a vaginal  exami- 
nation is  required  to  be  instituted,  for  the  purpose  of  watching  the  dilating 
process  going  on  in  the  os  uteri : but  the  frequency  of  return,  and  the 
strength  of  the  uterine  contractions,  will  in  some  measure  indicate  to  us 
the  changes  taking  place  in  that  organ  ; and  we  must  be  guided  by  those 
indications  in  regard  to  the  removal  of  the  plug, — provided  it  stanches  the 
flow  outwardly,  and  provided  also  there  are  no  evidences  of  internal  has- 
morrhage.  Although,  then,  I consider  the  tampon  may  be  occasionally 
useful,  I am  far  from  recommending  it  in  preference  to  other  means ; and 
I think  it  should  only  be  resorted  to  in  the  rigid,  unyielding  condition  of 
the  os  uteri  just  mentioned,  when  the  discharge  is  alarming,  and  can  b 
restrained  in  no  other  way,  and  when  an  attempt  at  delivery  would  e 
danger  the  structure  of  the  organ.* 

I have  given  the  student  to  understand  that  placental  presentations  ai 
always  fraught  with  extreme  peril ; I look  upon  them,  indeed,  as  the  mo 
dangerous  of  all  cases  of  haemorrhage ; and  many  causes  contribute  the; 

* Many  cases  have  come  under  my  notice,  where  plugging  the  vagina  under  placental  pre 
scntations  has  restrained  the  flow  of  blood  for  a time.  And  should  the  attendant  be  diffider, 
in  his  own  opinion,  and  anxious  to  obtain  the  counsel  of  a friend,  he  may  with  great  propri 
ety  have  recourse  to  this  measure  in  the  interval  that  must  elapse  before  assistance  can  arrive 
But  I would  strongly  advise  every  well-educated  surgeon,  if  the  bleeding  be  profuse  and  the 
os  uteri  lax  and  dilatable,  rather  to  undertake  the  delivery  himself,  and  alone,  than  send  to 
any  great  distance  for  aid ; because  every  hour’s  not  to  say  minute’s  delay,  under  such  cir- 
cumstances, increases  the  hazard  of  his  patient ; and  because  the  delivery  in  itself  is  not  very 
difficult. 


PLACENTAL  PRESENTATION. 


351 


share  towards  the  productionof  this  danger.  The  frequent  losses  of  blood 
which  occur  previously  to  the  accession  of  labour,  tend,  in  no  small  de- 
gree, to  depress  the  constitution,  and  render  it  unable  to  sustain  the  aggra- 
vated shock  occasioned  by  the  unusual  discharge  on  the  opening  of  ths  os 
uteri.  The  violent  gushes  which  generally  accompany  the  dilatation  of  the 
womb,  and  the  natural  and  praiseworthy  reluctance  which  most  practi- 
tioners feel  to  a forced  delivery  when  the  os  uteri  is  in  an  undilated  state, 
(and  this  very  feeling  may  induce  delay  beyond  the  period  of  safety — of 
which  I have  myself  known  instances,)  all  combine  to  render  this,  indeed, 
a fearful  case.  But  it  appears  to  me  that  still  another  must  be  added : I 
mean,  the  sudden  emptying  of  the  uterus  of  the  whole  of  its  contents  com- 
paratively rapidly ; and  that  too  at  a time  when  the  constitution,  weak- 
ened by  haemorrhage,  is  easily  affected  by  any  depressing  action.  We 
well  know  the  effect  of  suddenly  evacuating  the  water  in  ascites  ; we  know 
that  the  most  courageous  and  hardiest  persons  will  sometimes  fall  into  a 
state  of  syncope,  even  under  the  comparatively  trifling  operation  of  tap- 
ping; and  we  account  for  the  faintness  by  the  rapid  removal  of  that  pres- 
sure from  the  large  vessels  of  the  trunk — and  perhaps  from  the  viscera 
themselves — to  which  they  had  been  for  so  long  accustomed.  It  appears  to 
me  that  the  same  circumstances  obtain  in  delivery  under  placental  presen- 
tation, as  commonly  practised.  The  gravid  uterus  occupies  a very  large 
space  in  the  abdominal  cavity;  during  its  gradual  increase,  it  has  been 
exerting  a constantly  augmenting  pressure  on  all  the  parts  surrounding  it ; 
these  parts  accommodating  themselves  to  the  inconvenience  they  must  ne- 
cessarily suffer  during  pregnancy,  by  the  slowness  of  the  organ’s  develop- 
ment. But  when  its  contents  are  suddenly  removed — when  the  liquor 
amnii  is  allowed  to  escape,  and  with  it  the  foetus  is  extracted  also — an 
enormous  decrease  in  its  bulk  is  effected,  considerable  pressure  is  at  once 
taken  off, — and  that,  too,  at  a time  when  the  system  is  suffering  much  from 
previous  depressing  causes— and  we  cannot  wonder  that  collapse  occurs  as 
a consequence;  even  should  the  delivery  have  been  perfected  with  but 
slight  additional  loss  of  blood.  It  has  occurred,  therefore,  to  my  father,* 
(and  in  his  sentiments  I fully  join,)  that  in  some  aggravated  cases  it  might 
be  desirable  partially  to  evacuate  the  uterus,  and  wait  for  a short  period, 
before  completing^the  delivery,  provided  this  could  be  done  without  in- 
ducing a farther  separation  of  the  placenta  ; and  the  discharge  of  the  liquor 
amnii  seems  to  offer  us  a means  of  accomplishing  this  end.  For  this  pur- 
pose, however,  the  placenta  must  be  perforated  by  some  sharp  instrument 
—a  common  trochar  for  instance;  and  a probability  therefore  exists,  that 
foetal  blood  may  be  lost  by  the  laceration  of  one  or  more  placental  vessels. 
Such  a chance  of  injury  w?e  cannot  guard  against;  and  as  this  mode  of 


* Practical  Observations,  part  ii.  p.  189. 


352 


COMPLEX  LABOURS. 


proceeding  would  only  be  advisable  when  the  woman  is  very  much  de- 
pressed, and  when,  as  a consequence,  the  child  would  have  almost  invari- 
ably perished,  the  chance  of  its  being  born  alive  ought  scarcely  to  influ- 
ence practice.  I have  never  myself  resorted  to  this  expedient,  but  it  is  sug- 
gested on  the  principle  of  emptying  the  uterus  as  slowly  as  possible,  by  which 
both  the  pressure  is  removed  more  gradually,  and  also  a better  opportunity 
is  afforded  the  viscus  of  taking  on  itself  expulsive  action. 

It  is  more  than  probable  that  spirituous  stimuli  may  be  required  during 
the  process  of  extraction,  as  well  as  after  the  completion  of  the  birth. 
Since,  however,  their  exhibition  is  such  a nice  point,  it  must  be  regulated 
by  the  extremest  caution. 

Partial  placental  presentation. — As  there  is  no  part  of  the  internal 
surface  of  the  uterus  to  which  the  placenta  may  not  be  occasionally  at- 
tached, so  we  find  it  sometimes  'partially  placed  over  the  orifice  at  the  be- 
ginning of  labour ; one-third,  half,  or  two-thirds  of  the  disc  of  the  os  uteri 
being  covered  by  the  placenta,  and  the  remainder  occupied  by  the  mem- 
branes ; and  partial  placental  presentations  are  more  frequently  met  with 
than  cases  in  which  the  mass  is  centrally  implanted  over  it. 

Under  this  state  of  things  there  will  exist  the  same  liability  to  hemorrhage 
during  the  development  of  the  cervix  uteri,  as  in  the  case  just  described; 
— the  same  symptoms,  therefore,  during  the  last  months  of  pregnancy^ 
— the  same  sudden  and  occasional  floodings,  not  to  be  accounted  for  by 
any  apparent  external  cause — the  same  spontaneous  cessation.  On  the 
accession  of  labour-pains  also,  the  symptoms  will  be  equally  similar : we 
shall  observe  the  same  increase  of  discharge  on  the  return  of  each  pain, 
and  the  same  diminution  or  subsidence  in  the  interval  of  action ; but  the 
probability  is,  that  the  haemorrhage  will  not  be  so  profuse  because  we  r 
calculate  on  the  vessels  that  are  opened  being  both  fewer  in  number 
smaller  in  calibre. 

Diagnosis. — Although  so  similar  in  character  and  symptoms  to  the  c 
last  spoken  of,  partial  placental  presentations  are  by  no  means  so  hazi 
ous ; and  they  admit  of  a somewhat  modified  treatment.  They  can  c 
be  discriminated  by  a careful  vaginal  examination.  On  introducing 
finger  for  this  purpose,  the  edge  of  the  placenta  may  be  clearly  felt, 
the  membranes  passing  off*  from  it;  a portion  of  the  fleshy  mass,  thin 
moveable,  can  also  be  distinguished,  closing  a part  of  the  uterine  moi 
while  the  remainder  of  the  orifice  is  occupied  by  the  membranes,  thro 
which  the  presenting  part  of  the  child  may,  perhaps,  be  perceptibly 
cerned. 

It  is  very  possible,  if  the  os  uteri  be  much  dilated,  that  a considen 
portion  of  the  placenta  may  be  propelled  downwards  into  the  vagina,  ap- 


tS’xndaur^'Jjvffi 


PLACENTAL  PRESENTATION. 


353 


parently  hanging  loose  in  that  cavity,  but  still  connected  within  to  the  cer- 
vix uteri  above.  The  danger  will  generally  be  proportioned  to  the 
quantity  of  the  organ  implanted  over  the  uterine  mouth ; and  the  profuse- 
ness of  the  discharge  will  be  principally  regulated  by  the  degree  of  sepa- 
ration. 

Treatment — Previously  to  the  dilatation  of  the  os  uteri,  our  general 
management  must  be  precisely  similar  to  that  already  advised;  but  when 
labour  is  established,  it  must  entirely  depend  on  the  state  of  the  patient 
herself,  and  the  urgency  of  the  symptoms.  Should  the  sanguineous  ap- 
pearance be  but  trifling, — which,  however,  is  not  often  the  case, — the  la- 
bour may  perhaps  be  allowed  to  proceed  uninterfered  with ; but  should  a 
continued  discharge  be  going  on,  it  will  be  most  prudent  to  rupture  the 
membranes,  and  allow  the  liquor  amnii  to  drain  away ; and  this  may  with 
advantage  be  done,  whatever  degree  of  dilatation  the  os  uteri  may  have 
acquired,  and  whatever  degree  of  depression  the  patient’s  system  may 
have  suffered,  provided  the  head  present,  or  indeed  the  breech,  or  any  part 
of  the  inferior  extremities.  Nor  will  this  be  found  difficult  to  effect — 
either  the  finger-nail,  the  stilette  of  a catheter,  or  a pointed  quill,  being 
quite  sufficient  for  the  purpose.  If  the  os  uteri  be  covered  but  in  a trifling 
degree  by  the  placental  mass,  the  best  opportunity  is  afforded  of  com- 
pressing the  vessels  previously  opened,  by  the  descent  of  the  head  upon 
the  pelvic  brim,  and  of  increasing  the  expulsive  efforts  of  the  uterus  by 
the  augmented  stimulus  propagated  to  its  mouth.  And  if  the  placental  at- 
tachment be  more  considerable,  and  the  flooding  consequently  more  co- 
pious, so  that  artificial  delivery  subsequently  becomes  necessary,  the  uterus 
is  relieved  of  a part  of  its  contents  before  the  operation  is  commenced, 
and  no  small  degree  of  the  danger  necessarily  attendant  upon  the  case 
thereby  averted.  Another  desirable  effect  is  produced  by  the  diminution 
in  the  capacity  of  the  uterine  vessels  in  consequence  of  the  partial  contrac- 
tion of  the  parietes ; and  a third  by  the  probability  of  a farther  separation 
of  the  placenta  to  any  great  extent  being  much  lessened ; for  so  long  as 
the  membranes  are  entire,  it  stands  to  reason  that  the  placenta  is  likely  to 
be  detached  in  the  same  proportion  as  they  are  protruded  downwards 
into  the  vagina ; but  when  the  bag  is  destroyed,  and  the  head  presses  with 
some  power  against  the  mouth  of  the  womb,  the  chance  of  an  increased 
separation  is  materially  diminished,  as  well  as  a plug  formed  by  the  com- 
pression which  the  head  occasions.  Plate  XLYIII.  fig.  133,  shows  the 
placenta  partially  attached  over  the  uterine  mouth,  the  membranes  being 
still  entire  : fig.  134  the  same  case  after  the  water  has  been  evacuated.  It 
will  be  seen  that  the  head,  by  pressing  the  placenta,  forms  a plug,  which 
"is  likely  to  prevent  any  farther  loss  of  blood  ; while,  by  stimulating  the  os 
Uteri  by  the  same  pressure,  it  may  and  probably  will  occasion  a more 
45 


354 


COMPLEX  LABOURS. 


rapid  dilatation  of  that  organ.  The  ergot  may  be  usefully  exhibited  after 
the  membranes  are  broken. 

Nevertheless,  it  must  not  be  supposed  that  a natural  termination,  though 
so  highly  desirable,  will  invariably  follow  the  proceeding  I have  recom- 
mended : the  after  conduct  of  the  case,  then,  must  depend  on  the  continu- 
ance of  the  haemorrhage,  and  the  effect  produced  on  the  constitution.  If 
the  flooding  be  at  once  stayed,  and  the  patient  not  much  depressed,  our 
indication  would  evidently  be  to  allow  Nature  an  opportunity  of  perfecting 
the  delivery  unaided.  Even  if  a slight  oozing  continued, — provided  the] 
uterus  was  acting  with  vigour, — the  labour  progressing,  and  the  powers 
of  life  remained  tolerably  good, — it  would  be  injudicious  to  interfere,  be- 
cause so  much  less  danger  attends  a natural  than  an  artificial  birth.  But 
should  the  constitution  become  gradually  weakened,  should  the  pulse  flag, 
and  faintness  occur,  we  must  resort  to  manual  delivery ; and  we  shall 
find  the  operation  of  turning  usually  most  applicable  to  the  case. 

From  the  acknowledged  probability  that  delivery  may  in  the  end  be  re- 
quisite, an  objection  has  been  strongly  urged  against  this  plan,  under  the 
impression,  that,  after  the  escape  of  the  liquor  amnii,  the  uterus  may  so 
powerfully  compress  the  foetal  body  as  to  prevent  the  introduction  of  the 
hand  for  the  accomplishment  of  the  operation  of  turning.  I have  already 
laid  it  down  as  a principle,  that  under  transverse  presentations  the  passage 
of  the  hand  and  version  of  the  foetus  is  comparatively  easy  while  the  mem- 
branes are  preserved  whole,  but  that  it  becomes  an  operation  of  the  utmost 
difficulty  when  the  foetal  body  is  closely  embraced  by  the  uterine  parietes. 
It  has  been  supposed  that  the  same  difficulty  would  be  met  with  under  the 
circumstances  I have  just  described.  Such  reasoning,  however,  is  founded 
on  false  data,  and  is  in  itself,  therefore,  untenable ; for  should  the  uterus 
act  with  sufficient  energy  to  oppose  a serious  obstacle  to  the  introduction 
of  the  hand,  its  contraction  will  be  vigorous  enough  to  propel  the  head  sqj 
forcibly  against  the  os  uteri  as  to  check  the  discharge  by  its  own  pressur 
and  eventually  to  expel  the  child, — provided,  indeed,  the  pelvis  be  of  ore 
nary  capacity,  and  the  soft  parts  have  acquired  their  usual  distensibilit 
When  the  foetus  lies  transversely,  it  cannot  pass  by  the  agency  of  natu 
alone,  because  of  its  unfavourable  position ; but  if  the  vertex  offers  itsf 
under  a partial  presentation  of  the  placenta,  such  an  impediment  cann 
exist. 

After  having  punctured  the  membranes,  then,  the  patient  still  requir*. 
careful  and  constant  watching;  and  we  must  be  prepared  to  act  w 
promptitude  should  circumstances  require  our  farther  interference.* 

* Of  partial  presentation  of  the  placenta,  or  its  implantation  on  the  neck  of  the  womb,  cl  • 
to  the  os  uteri,  within  reach  of  the  finger  under  examination,  it  has  fallen  to  my  lot  to  see 
merous  cases.  I have  the  detailed  histories  of  forty. four  occurring  between  1823  and  18--, 


ACCIDENTAL  HAEMORRHAGE. 


355 


b.  ACCIDENTAL  HAEMORRHAGE. 

The  second  variety  of  haemorrhage  before  delivery  depends  on  a partial 
separation  of  the  placenta  from  its  attachment  to  the  body  or  fundus  of 
the  uterus : and  as  it  is  evident  that,  unless  the  mass  be  situated  over  or 
near  to  the  os  uteri,  flooding  need  not  necessarily  accompany  the  dilatation 
of  the  orifice,  so  it  is  equally  plain  that  the  discharge  in  the  case  under  con- 
sideration must  be  regarded  as  purely  of  an  accidental  nature. 

It  is  probable  that  before  the  termination  of  gestation  one  or  more 
attacks  of  haemorrhage  may  appear ; and  that  the  first  may  be  traced  to 
a blow  or  a fall,  sudden  or  unusual  exertion,  or  violent  mental  agitation : 
but  in  general  it  does  not  show  itself  till  the  beginning  of  labour,  and  may, 
perhaps,  be  referred  to  undue  and  irregular  action  of  the  uterine  fibres,  at 
that  particular  part  against  which  the  organ  is  apposed.  It  it  mostly 
observed  in  accidental  haemorrhage,  that,  after  the  establishment  of 
labour,  the  discharge  is  diminished  in  quantity,  or  wholly  suspended, 
while  the  uterus  is  contracting ; and  returns  more  copiously  in  the  inter- 
vals of  action.*  In  both  these  respects  the  suspicious  symptoms  differ 
materially  from  those  which  would  lead  us  to  believe  that  the  placenta 
was  implanted  over  the  os  uteri ; for  I have  stated  that  when  it  offers 
itself  before  the  child,  as  the  uterine  neck  expands  by  a gradual  growth — 
the  fibres  dilating  circularly  from  above — its  surface  slips  away  from  its 
connexion  with  the  placenta.  I have  shown  that  this  separation  is  almost 
always  attended  by  discharges  of  blood  at  uncertain  intervals  during  the 
last  few  weeks  of  pregnancy,  coming  on  without  any  assignable  cause ; 


all  of  which  I have  personally  attended.  It  is  curious  that  of  these  forty-four,  in  six  the  foetus 
offered  itself  at  the  os  uteri  with  the  breech,  and  in  five  transversely.  In  most  of  these  cases, 
however,  labour  came  on  prematurely  ; but  I have  remarked  also,  that  under  complete  placental 
presentations,  a preternatural  position  of  the  foetus  is  more  frequent  than  ordinary.  In  forty 
the  membranes  were  ruptured  some  time  before  delivery  was  proceeded  in  ; in  thirteen  of  these 
the  labour  was  terminated  by  the  agency  of  the  natural  powers  alone ; in  twenty-six,  turning 
was  accomplished,  and  that  without  much  difficulty,  the  discharge  not  ceasing  on  the  evacua- 
tion of  the  liquor  amnii,  but  in  the  great  majority  being  most  materially  lessened  ; and  one 
J "was  terminated  by  the  forceps.  In  three  of  the  transverse  cases  the  operation  was  undertaken 
immediately.  Eight  of  these  patients  died;  one  from  malignant  puerperal  fever,  which  was 
raging  at  the  time;  another  from  an  inflammatory  attack  ten  days  after  delivery;  two  in 
whom  the  placenta  was  strongly  adherent  to  the  cervix  uteri,  giving  much  trouble  in  its  se- 
paration;  and  the  remainder  apparently  from  the  excessive  loss  of  blood  suffered  previously  to 
delivery  being  effected  : one  of  the  cases  in  which  the  child  lay  transversely  was  among  these 
latter. 

* This  is  easily  explained  by  the  pressure  which  the  parietes  of  the  gravid  uterus  exert  on 
the  ovum  during  contraction,  and  the  temporary  plug  consequently  created  at  the  open  orifices 
of  the  uterine  vessels. 


356  COMPLEX  LABOURS. 

that  on  the  accession  of  labour  also,  with  each  contraction  there  is  usually 
an  increase  of  the  bleeding,  and  a diminution  when  the  pain  declines. 

Although  of  a character  to  excite  considerable  anxiety,  this  case  is 
very  much  inferior  in  danger  to  placental  presentations,  either  partial  or 
entire.  The  diagnosis  from  placental  presentation  is  not  difficult ; it  is 
known  by  the  membranes  being  discernible,  protruding  more  or  less 
through  the  os  uteri,  and  the  placenta  being  completely  out  of  the  reach 
of  the  finger:  it  remains  that  we  should  consider  the 

Treatment. — On  this  subject  there  still  prevails  a diversity  of  opinion 
among  practical  men,  though  the  great  majority  strongly  recommend  the 
adoption  of  the  plan  I myself  pursue, — an  early  rupture  of  the  mem- 
branous cyst.  This  simple  proceeding  I have  almost  invariably  found  sub- 
due the  discharge,  in  the  case  under  consideration,  even  more  completely 
than  when  the  placenta  was  partially  implanted  over  the  uterine  orifice; 
and,  as  far  as  my  observation  has  gone,  it  has  been  attended  with  the 
happiest  results. 

Before  the  commencement  of  labour,  indeed,  the  general  treatment 
already  recommended  may  be  enjoined ; and  it  will  frequently  be  found 
that  the  discharge  is  arrested  by  a rigid  adherence  to  the  anti-hsemor- 
rhagic  system  : but  when  the  flooding  continues  while  the  os  uteri  is 
dilating,  other  means  must  be  had  recourse  to  beyond  those  of  a mere 
palliative  kind ; and  the  evacuation  of  the  liquor  amnii,  on  the  one  hand, 
and  immediate  delivery  on  the  other,  have  each,  even  in  the  present  day,; 
their  advocates.* 

The  great  advantage  resulting  from  letting  off  the  waters  of  the  ovum 
have  already  been  noticed,  when  partial  placenta-presentations  were 
under  discussion.  The  vessels  of  the  uterus  are  diminished  in  size  by  the 
* •'  ' , J 

* Till  within  the  last  few  years  no  part  of  obstetric  practice  was  founded  on  more  uncertain  j 
principles  than  the  treatment  of  haemorrhages  before  delivery, — some  authorities  advising  the' 
case  to  be  left  to  the  agency  of  Nature  alone,  others  to  puncture  the  membranes,  and  others 
again  contending  for  immediate  delivery  in  every  instance, — but  all  agreeing  that  when  the 
haemorrhage  is  profuse,  and  the  patient’s  life  is  placed  in  imminent  hazard,  emptying  the 
uterus  artificially  offers  the  only  chance  of  safety.  Arid  this  discrepancy  of  opinion  and 
advice  evidently  arose  from  the  true  nature  of  the  different  causes  of  the  discharge  not  being 
well  understood.  Since  the  excellent  treatise  of  Rigby,  however,  has  become  so  generally 
known  to  the  profession,  not  only  is  the  obscurity  in  which  these  cases  were  shrouded  re- 
moved,  but  a fixed  and  determined  principle  of  practice  is  established  for  our  guidance. 

Guillemeau,  the  celebrated  pupil  of  the  still  more  celebrated  Pare,  following  the  suggestions 
of  his  preceptor,  advised  delivery  by  the  feet  in  all  cases  of  dangerous  haemorrhage;  and  this 
method  was  almost  universally  adopted  till  the  time  of  Julian  Clement,  who  insisted  on  the 
more  simple  plan  of  rupturing  the  membranes : and  to  Puzos,  the  pupil  of  Clement,  the  credit 
is  due  of  first  publicly  advocating  this  practice.  Still,  however,  as  little  or  no  distinction  was 
drawn  between  those  cases  in  which  the  placenta  presented  first,  and  haemorrhages  of  a purely 
accidental  nature,  the  practice  could  not  be  considered  as  based  on  scientific  or  sure  grounds, 
until  Rigby,  with  the  most  praiseworthy  zeal,  directed  his  observant  mind  to  the  subject. 


ACCIDENTAL  HAEMORRHAGE. 


357 


contraction  of  the  uterine  fibres the  open  orifices  are  in  a degree  plug- 
ged by  the  parietes  being  brought  into  closer  and  stronger  contact  with 
that  portion  of  the  placental  mass  disunited  from  the  uterine  surface ; and 
the  pains  are  usually  increased  in  frequency  and  power  by  the  augmented 
stimulus  impressed  upon  the  os  uteri.* * * § 

Nevertheless  the  utility,  as  well  as  the  propriety  of  rupturing  the  mem- 
branes in  accidental  haemorrhage  is  denied  by  Hamilton, f Burns, J Stew- 
art,§ and  some  other  practitioners.  Three  great  objections  have  been 
taken  to  the  practice  :|| — first,  that  gestation  is  necessarily  suspended  by 
the  evacuation  of  the  waters  of  the  ovum ; — secondly,  that  the  time  is 
uncertain  at  which  delivery  will  be  perfected  after  the  operation, — during 
which  interval  the  dangerous  symptoms  may  be  much  aggravated; — and, 
thirdly,  that  as  puncturing  the  membranes  will  not  always  suspend  the 
flow  of  blood,  should  delivery  become  requisite,  its  performance  will  be 
rendered  extremely  difficult,  in  consequence  of  the  powerful  contraction 
of  the  uterine  parietes  around  the  foetal  body.  To  the  first  objection  the 
answer  is  easy  and  conclusive ; for,  since  we  may  presume  that  labour 
has  already  commenced  by  the  dilatation  of  the  uterine  mouth,  the  pro- 
cess of  gestation  must  have  been  arrested  before  the  operation  is  resorted 
to.  Even  should  the  term  of  pregnancy  be  distant, — inasmuch  as  large 
losses  of  blood  usually  excite  uterine  action,  and  we  may  therefore  pre- 
sume that  a premature  expulsion  of  the  ovum  will  ensue, — puncturing  the 
membranes  can  but  hasten  the  event ; it  does  not  originate  the  disposition. 
Besides,  should  the  woman’s  life  be  endangered  by  the  profuseness  of  the 
discharge, — since  the  probability  is  that  the  complete  evacuation  of  the 
uterine  cavity  will  alone  place  her  in  a state  of  safety, — the  preservation 
of  an  immature  foetus  cannot  be  put  into  competition  with  the  chance  of 
recovery  afforded  her.  The  uncertainty  of  time  at  which  effective  uterine 

* This  treasure  is  sanctioned  by  the  authority  of  Denman,  Baudelocque,  Merriman,  Blun- 
dell, my  father,  and  many  other  men  of  acknowledged  practical  experience.  Rigby  has 
; reported  a great  number  of  cases  in  which  the  rupture  of  the  membranes  entirely  put  a stop 
3%  the  previous  discharge, — and  he  states  that  he  never  had  occasion  to  turn  the  child  in  any 
instance  where  this  expedient  was  resorted  to.  Merriman  (Synop.,  p.  119)  mentions  that  he 
‘has  adopted  the  same  means  in  upwards  of  thirty  cases  of  accidental  haemorrhage;  “that  as 
Vyet  he  has  had  no  reason  to  be  dissatisfied  with  the  plan,  for  in  every  instance  the  discharge 
has  either  entirely  ceased,  or  been  so  much  diminished  as  to  secure  the  safety  of  the  patient; 
and  yet  there  were  some  among  these  patients  whose  cases,  from  profuse  haemorrhage,  were 
abundantly  alarming.”  In  my  own  practice,  out  of  twenty  five  successive  cases  of  this  kind, 
of  very  aggravated  nature,  occurring  within  the  space  of  eleven  years  in  twenty-three  in- 
stances the  labour  was  terminated  naturally  and  safely  after  the  rupture  of  the  membranes, 
and  in  two  the  loss  of  blood  had  been  so  profuse,  before  I saw  the  patients,  as  to  induce  me 

to  deliver  artificially;  in  both  instances,  with  a fatal  result. 

t Pract.  Obs.,  1840,  p.  331.  t Trincip.  of  Mid.,  5th  edit.,  p.  318. 

§ On  Uterine  Haemorrhage,  p.  92,  &c. 

II  See  Dewees,  parag.  1051  et  seq.  He  only  admits  puncturing  the  membranes  to  be  safe 
>yhen  the  o«  uterj  is  dilated  or  dilatable. 


358 


COMPLEX  LABOURS. 


action  will  be  established,  has  been  adduced  as  another  serious  objection 
and  this  appears  to  me  as  untenable  as  the  former : for  in  my  own  prac 
tice  I have  usually  found  the  contractions  speedily  increased,  both  ii 
frequency  and  strength,  after  the  measure  has  been  resorted  to;  and  th< 
same  observation  must  be  made  of  a perusal  of  the  cases  detailed 
Rigby.  The  third  objection,  at  first  sight,  would  seem  the  most  plausi 
ble ; but  I have  already  replied  to  it  by  observing,  that  if  the  uteru 
contracts  powerfully  enough  to  refuse  admittance  to  the  hand,  its  actioi 
will  be  sufficient  to  expel  the  foetus,  or  at  least  so  to  compress  the  opei 
vessels  as  to  put  a stop  to  any  farther  flow  of  blood  in  an  immoderat< 
degree.  But  if  confirmation  were  required,  I might  with  confident 
advert  to  the  experience  of  Rigby,  Merriman,  my  father’s  and  my  own 
in  corroboration  of  the  statements  which  I have  just  advanced. 

For  reasons  before  given,  I consider  it  my  duty  strongly  to  recommem 
this  practice  in  preference  to  immediate  delivery : for  my  opinion  is  per 
fectly  at  variance  with  Professor  Burns,*  who  asserts  that  experience  ha: 
taught  us  puncturing  the  membranes  cannot  be  relied  on.  On  the  con 
trary,  we  may  affirm  that  experience  taught  Smellie,f  Denman, J Rigby ,{ 
Merriman, ||  Blundell,!  Davis,**  Conquest, ff  Ingleby,JJ  and  many  othei 
eminent  men,  not  only  of  this  country  but  on  the  continent  also,  that  this 
easy  and  gentle  expedient  could  be  trusted  in  the  great  majority  of  in: 
stances ; and  personal  observation  has  long  impressed  me  with  the  convic- 
tion of  its  high  value.  Nor  am  I more  disposed  to  agree  with  the  Profes? 
sor  in  his  eulogium  on  the  use  of  the  plug,§§  in  cases  where  rigidity  of  the 
os  uteri  precludes  the  possibility  of  immediate  delivery,  although  sanc- 
tioned by  the  authority  of  De wees, ||  ||  Capuron,!!Gardien,***and  Duges;ff| 
because,  notwithstanding  the  blood  may  be  prevented  flowing  externally 
it  may  still  collect  in  such  quantities  in  utero  as  to  destroy  life.JJJ  If  sucf 
be  the  case,  then,  the  tampon  must  prove  a dangerous  application,  anc 
should  not  supersede  the  rupture  of  the  membranes.  It  is  certainly  possi 

* Principles  of  Mid.,  5th  edit.,  p.  318. 

t Vol.  i.  chap.  iii.  sect.  3 ; sec  also  vol.  ii.  p.  268,  and  vol.  iii.  p.  113. 

t Chap.  xv.  sect.  7.  § On  Uterine  Haemorrhage,  4th  edit.,  p.  31.' 

II  Synopsis,  p.  118.  IT  Obstetricy,  by  Castle,  p.  454. 

**  Obstetric  Med.,  1053.  +f  Outlines  of  Mid.,  p.  157. 

tt  On  Uterine  Haemorrhage,  p.  125.  §§  Op.  Cit.,  p.  302. 

IIH  Parag.  610  and  1027.  1T1T  L’Art  des  Accouchemens,  p.  391. 

***  Traite  d’ Accouchemens,  vol.  ii.,  p.  414. 

ttf  Man.  d’Obstetr.,  deuxieme  edit.,  p.  230. 

ttt  The  practitioners,  indeed,  whose  names  I have  quoted  in  the  text,  deny  the  possibility  Jtv 
such  an  occurrence,  while  those  of  our  own  country  (particularly  Hunter,  Denman,  Barlow,  I 
and  Merriman)  look  upon  the  uterus,  at  the  termination  of  pregnancy,  as  capable  of  contain- 1 
ing  a body  much  larger  than  the  ovum,  and  fear  an  internal  accumulation  of  blood  in  conse- 
quence  of  its  distensi bility . Of  this  fact,  indeed,  more  than  one  instance  has  come  within  my 
own  knowledge. 


COMPLICATED  PLACENTAL  PRESENTATIONS.  359 

ble  that  completely  filling  the  vagina  may  be  advantageous  in  cases  where 
the  membranes  have  been  broken,  where  the  os  uteri  continues  rigid  and 
undilated,  and  where  any  attempt  at  delivery  must  be  attended  with  dan- 
ger to  its  structure ; but  such  cases,  at  the  full  period  of  pregnancy,  ac- 
cording to  my  own  experience,  I should  look  upon  as  of  very  rare  occur- 
rence indeed. 

After  the  evacuation  of  the  liquor  amnii,  it  may  be  serviceable  to  admi- 
nister the  ergot — unless,  indeed,  the  mouth  of  the  womb  be  preternaturally 
rigid:  stimuli  may  be  required  if  the  patient  be  much  depressed;  but 
opium,  for  the  reasons  more  than  once  adduced,  I should  avoid.  Fric- 
tion, and  moderate  pressure  on  the  uterine  tumour,  may  have  the  effect  of 
exciting  increased  action,  and  the  dilatation  of  the  os  uteri  may  be  for- 
warded by  the  fingers  introduced  carefully  within  it  during  a pain — a 
means  recommended  by  many  practitioners,  but  one  which  I have  myself 
seldom  found  it  necessary  to  employ. 

Should  the  discharge  continue  to  flow  outwardly  with  profuseness,  or 
should  indications  of  internal  bleeding  be  present— the  symptoms,  indeed, 
being  those  of  loss  of  blood  generally,  together  with  a flabby  and  relaxed 
state  of  the  uterine  parietes — delivery  must  be  had  recourse  to  without 
delay,  as  offering  the  only  reasonable  chance  of  safety.* 

Placental  'presentation  complicated  with  transverse  position  of  the  foetus, 
or  small  pelvis.— It  must  be  evident  that  when  the  placenta  is  situated 
either  entirely  or  partially  over  the  os  uteri,  the  child  may  present  with 
the  breech  or  transversely.  Under  an  entire  placental  presentation,  such 
a preternatural  position  of  the  foetus  would  not  influence  our  practice  ; 
because  delivery  would  be  required,  not  in  consequence  of  the  mode  in 
which  the  child  lay  in  utero,  but  because  of  the  unfortunate  misplacement 
of  the  placenta  itself; — and,  indeed,  it  is  more  than  probable  that  its  posi- 
tion would  not  be  detected  until  the  hand  was  introduced  into  the  uterine 
cavity:  under  either  case,  extraction  must  be  made  by  the  feet.  Should 
the  placenta,  however,  be  but  partially  occupying  the  orifice,  while  the 
^reech  is  at  the  brim,  the  membranes  may  be  ruptured  and  time  allowed 
ft>r  its  descent,  provided  the  flooding  be  restrained.  But,  on  the  other 
jiand,  if  the  child  lie  across  the  pelvic  brim,  it  would  be  better  to  under- 
take the  delivery  at  once— to  treat  the  case,  indeed,  as  a transverse  pre- 
sentation— proceeding  with  extraction  as  slowly  as  is  consistent  with  the 
safety  of  the  infant. 

On  the  subject  of  hsemorrhage  before  delivery,  I would  strongly  recommend  the  student 
to  peruse  with  attention  Rigby’s  Essay,  already  alluded  to,  as  well  as  the  much  more  recent 
treatise  by  Ingleby  ; which  latter  I look  upon  as  one  of  the  most  practically  useful  productions 
of  the  day  in  our  department  of  medicine ; and  with  most  of  the  observations  contained  in 
which  I perfectly  coincide. 


360 


COMPLEX  LABOURS. 


A placental  presentation  may  also  be  complicated  with  a distortec 
pelvis ; so  that,  though  we  may  have  turned  the  foetus  and  brought  dowi 
the  breech  and  body,  we  may  be  unable  to  extract  the  head.  Under  sucl 
circumstances,  the  cranium  must  be  perforated  in  the  manner  before  ex 
plained.*  This  is  a complication  which  seldom  occurs,  but  it  has  hap 
pened  to  me  to  meet  with  three  such  cases,  and  very  embarrassing  I fount 
them.  Much  time  must  be  occupied  in  the  delivery,  and  it  might  be  ima 
gined  that  during  it  the  haemorrhage  would  be  profuse  : such,  however,  for 
tunately  was  not  the  case  in  either  of  the  instances  I attended.  In  all,  th( 
head  was  perforated  behind  the  ear ; and  the  delivery  was  accomplishet 
with  less  difficulty  than  I expected. 

Our  first  duty,  then,  in  floodings  before  delivery,  consists  in  ascertaining 
whether  the  placenta  presents  over  the  os  uteri ; and  if  so,  whether  th< 
orifice  be  wholly  or  partially  occupied  by  it.  If  it  be  found  entirely  cover 
ing  the  mouth  of  the  womb,  we  must  turn  the  child  as  soon  as  that  orgar 
is  dilated  to  the  size  of  half  a crown,  or  even  before,  should  it  be  suffi 
ciently  relaxed  and  the  flooding  continue  violent ; if  partially,  we  ma} 
rupture  the  membranes — provided  the  head  present — and  hold  ourselve; 
in  readiness  to  deliver  by  turning,  expecting  that  probably  the  flooding 
although  it  may  abate,  will  not  quite  cease.  If  no  part  of  the  placenta  b( 
discoverable  by  the  finger,  we  may  rupture  the  membranes  as  early  a? 
possible,  and  hope  by  this  means  to  put  a stop  to  the  haemorrhage;  but  a 
the  same  time  we  must  be  prepared  to  turn,  in  case  our  expectations  arf 
disappointed.  We  may  exhibit  the  ergot  of  rye  in  most  cases  ; give  sti 
muli  if  they  be  required ; and  should  the  os  uteri  be  rigid  and  undilatec 
under  placental  presentation,  either  entire  or  partial,  or  under  accidenta 
haemorrhage  after  the  membranes  are  broken,  we  may  perhaps  venture 
to  plug  the  vagina ; but  if  we  do  this,  we  must  keep  a close  watch  on  oui 
patient,  less  internal  flooding  be  going  on.f 

Haemorrhage  subsequent  to  the  rupture  of  the  membranes. — A large 
loss  of  blood  seldom  occurs  after  the  membranes  have  ruptured  before  the 
birth  of  the  head,  unless  there  have  been  haemorrhage  previously ; but  if  a 
discharge  should  appear  to  such  a degree  as  to  call  for  our  interference 


* Page  298. 

t Peu,  (Pratique  des  Accouchemens,  1694,  p.  454,)  La  Motte,  (Obe.  249,)  Levret,  (Accouche- 
mens  Laborieux,  1770,  p.  205,)  and  Baudelocque,  (parag.  1084,  trans.,)  cite  instances  in  whiclj 
it  was  supposed  that  a rupture  of  the  umbilical  cord  produced  haemorrhage  alter  the  mem. 
branes  had  broken;  but  in  this  case  we  should  not  expect  the  flow  to  be  profuse,  and  as  the 
blood  lost  would  be  entirely  foetal,  no  effect  would  be  produced  on  the  mother’s  system.  This 
is  a very  rare  complication  of  labour ; and  the  belief  in  the  possibility  of  its  occurrence  ought 
not  to  influence  our  practice  one  way  or  other. 


HAEMORRHAGE  AFTER  THE  CHILD’S  BIRTH.  361 

delivery  must  be  resorted  to — by  turning,  if  the  head  be  above  the  brim 
of  the  pelvis,  and  the  os  uteri  not  thoroughly  dilated — by  the  long  forceps, 
if  the  head  have  entered  the  pelvis  too  low  to  allow  of  our  raising  it  for 
the  introduction  of  the  hand  into  the  uterus,  but  not  low  enough  to  enable 
us  to  feel  an  ear — and  by  the  short  forceps,  or  the  vectis,  if  one  or  both 
ears  be  distinctly  within  reach  of  the  finger.  One  or  other  of  these  me- 
thods will  generally  be  found  adequate  to  the  end ; but  should  there  exist 
a small  pelvis,  tumours  or  preternatural  rigidity  of  the  soft  parts,  we  may 
be  obliged  to  perforate  the  head. 

It  sometimes  happens,  that  after  the  head  is  born,  a considerable  time 
elapses  before  the  uterus  again  acts  to  expel  the  shoulders  and  body ; and 
during  this  interval,  flooding  may  come  on.  In  such  a case,  we  may  en- 
deavour to  stimulate  the  organ  to  increased  energy  by  pressure  and  fric- 
tion, and  the  exhibition  of  the  ergot;  and  we  may  expedite  the  delivery 
by  gentle  and  careful  traction,  in  the  hope  that  the  uterus  will,  as  it  were, 
follow  the  body  of  the  child  during  its  extraction,  separate  and  throw  off 
the  placenta,  and  eventually  close  its  cavity  and  seal  its  vessels. 

Haemorrhage  after  the  birth  of  the  child. — Haemorrhage  under  labour 
by  far  the  most  frequently  occurs  after  the  birth  of  the  child,  and  pre- 
viously to  the  expulsion  of  the  placenta ; and  the  flow  is  often  most  sudden, 
rapid,  and  profuse.  At  the  very  time,  probably,  when  the  husband  and 
friends  are  congratulating  themselves  on  what  they  consider  the  fortunate 
termination  of  the  case,  and  when  the  medical  attendant  is  joining  in 
those  congratulations,  danger  is  insidiously  hovering  around,  and  death  is 
sometimes  rapidly,  though  secretly,  approaching. 

Flooding  after  the  child’s  birth  is  dependent  on  the  same  general  causes 
as  before  its  expulsion  namely,  the  separation  of  the  placenta,  more  or 
less,  from  its  uterine  attachment,  and  the  womb  not  being  capable  of  con- 
tracting its  cavity  so  as  to  render  its  vessels  comparatively  impervious. 
We  know  that  unless  the  uterine  cavity  be  empty,  its  perfect  contraction 
is  prevented,  and  consequently  the  complete  closure  of  the  vessels  is  im- 
peded ; and  that  so  long  there  is  a great  probability,  nay,  almost  a cer- 
tainty, of  haemorrhage  occurring.  If,  then,  the  placenta  be  partially  or 
wholly  retained  in  the  uterus,  and  a portion  of  it  be  separated  from  its 
attachment,  the  vessels  must  continue  open,  and  the  woman  must  there- 
fore sustain  more  or  less  discharge. 

There  is  always,  as  I before  mentioned,  (p.  1 16)  a certain  amount  of  blood 
lost  upon  the  separation  of  the  placenta  and  its  protrusion;  usually  not  exceed- 
ing a few  ounces : and  this  seems  to  consist  of  little  more  than  that  quan- 
tity which  was  contained  within  the  uterine  vessels,  and  which  is  squeezed 


46 


362 


COMPLEX  LABOURS. 


out  mechanically,  through  their  open  orifices,  by  the  contraction  of  the 
uterine  fibres ; so  that  scarce  any  is  lost  to  the  system  generally.  Bui 
when  the  discharge  is  copious,  all  the  vessels  of  the  body  are  proportion- 
ably  emptied ; and  from  the  rapidity  with  which  the  blood  flows,  we  can- 
not wonder  at  the  instantaneous  depression  which  sometimes  follows. 

It  has  been  advised,  (p.  137)  that  immediately  after  the  child  is  separated., 
and  transferred  to  the  care  of  an  attendant,  the  right  hand  should  be  placed 
between  the  thighs  of  the  patient,  upon  the  abdomen,  to  ascertain  the  state 
of  the  uterus,  with  regard  to  the  degree  of  contraction  it  has  taken  or 
itself,  and  whether  or  not  the  placenta  has  passed  from  its  cavity ; and  3 
have  mentioned  that  there  are  five  conditions  in  which  it  may  be  found 
differing  essentially  one  from  the  other,  and  each  indicating  a state  ol 
greater  or  less  security. 

After  having  made  this  external  examination,  I have  also  directed  thal 
the  first  finger  of  the  right  hand  should  be  passed  into  the  vagina,  to  exa- 
mine  for  the  placenta  before  the  bed-side  of  the  patient  is  left,  I have 
stated  that  we  may  feel  tolerably  well  persuaded  the  placenta  is  in  the 
uterine  cavity,  if  that  organ  be  found  large  externally,  but  that  we  become 
positively  certain,  if,  on  running  the  finger  along  the  funis  umbilicalis  uf 
to  the  pelvic  brim,  we  cannot  detect  the  mass ; because,  if  it  be  lodging  ir 
the  vagina,  it  would  be  within  our  easy  reach,  | 

The  reader  will  find  at  pages  141—2  a caution  against  any  attempt  to 
remove  the  placenta  from  the  cavity  of  the  uterus  by  traction  at  the  funis 
umbilicalis.  Such  an  attempt  I look  upon  as  dangerous,  and  therefore 
highly  to  be  deprecated,  unless  the  insertion  of  the  cord  be  most  easily 
discoverable,  and  unless  the  principal  bulk  of  the  mass  can  be  perfectly 
surrounded  by  the  finger,  introduced  as  in  a common  examination. 

With  these  cautions  in  our  mind,  then,  presuming  the  patient  free  from 
flooding,  we  are  to  wait  a certain  length  of  time  for  the  expulsion  of  thfi 
placenta  from  the  uterine  cavity : but  that  time  must  necessarily  have  a 
limit.* 

It  appears  to  me  that  in  the  present  day  we  are  in  the  habit  of  following 

* The  management  of  the  placenta  has  at  different  ages  been  conducted  on  the  most  dia- 
metrically opposite  principles.  From  the  writings  of  Hippocrates  (Liber  de  Superfeet.,  cap.  iii.) 
we  gather  that  it  was  not  the  custom  to  use  any  means  but  the  most  gentle  for  the  purpose  of 
extracting  it;  but  Celsus  (lib.  vii.  cap,  29)  plainly  counsels  us  to  introduce  the  right  hand  into 
the  uterus,  and  remove  the  secundines,  quoties  infans  protractus  est.  Since,  however,  the | 
chapter  in  which  these  words  occur  is  dedicated  to  the  method  to  be  employed  for  delivering 
a dead  child,  and  since  they  immediately  follow  his  instructions  to  that  effect,  we  may  natu- 
rally conclude  that  this  interference  was  only  recommended  after  a forced  delivery  had  been 
resorted  to,  and  not  in  common  natural  cases;  and  the  word  protractus  seems  to  favour  such 
an  opinion,  It  lias  been  supposed,  indeed  that  Celsijs  counselled  this  hasty  removal  of  the 


RETAINED  PLACENTA. 


363 


the  most  rational  and  judicious  practice,  in  regard  to  the  management  of 
the  placenta,  which  has  ever  been  adopted.  With  the  fatal  consequences 

placenta  upon  all  occasions;  and  Denman  (chap.  xv.  sect.  8)  has  evidently  adopted  this  view; 
but  I cannot  think  it  is  justified  by  the  expression  employed.  iEtius,  (tetrab.  iv.  sermo  iv. 
cap.  24,)  who  borrows  this  part  of  his  work  also  from  Philumen,  recommends  that  the  pla- 
centa, when  retained,  should  be  removed  by  the  introduction  of  the  left  hand;  and  that  if  the 
os  uteri  be  shut,  and  the  operation  consequently  rendered  difficult,  relaxing  means  should  be 
used  : that  the  endeavours,  however,  should  only  be  persisted  in  for  the  first  and  second  day, 
and  if  unsuccessful,  that  the  woman  must  no  longer  be  fatigued;  for  in  a few  days  the  mass 
will  putrify,  and  come  away  in  a dissolved  state.  Pare  (lib.  xxiv.  cap.  17)  recommended  the 
removal  of  the  placenta  immediately  the  child  was  born;  but  at  the  same  time  cautioned  his 
readers  that  it  was  to  be  done  in  the  gentlest  and  softest  manner — first,  by  pulling  at  the  funis ; 
and  if  that  did  not  succeed,  by  the  introduction  of  the  hand  into  the  uterus.  Park’s  advice  was 
but  partially  followed;  the  practice  inculcated  was  implicitly  adhered  to  for  many  years,  while 
the  excellent  cautions  by  which  it  was  enveloped  were  entirely  forgotten ; and  hence  the  most 
disastrous  effects  resulted.  The  hand  was  rudely  thrust  into  the  uterus  on  all  occasions,  and 
the  placenta  as  rudely  torn  away.  Nor  did  this  mischievous  custom  receive  a check  in  Eng- 
land till  Dr.  Hunter  determined  to  oppose  it  with  all  his  authority;  for  the  instantaneous  with- 
drawal of  the  placenta  was  taught  by  Chapman  in  1733,  and  sanctioned  by  Manningham  in 
1739,  in  the  practice  at  the  lying-in  ward  of  St.  James’s  Infirmary,  which  was  the  first  at- 
tempt at  the  establishment  of  an  hospital  for  parturient  women  in  this  metropolis.  In  Snaellie, 
also,  we  find  the  same  system  prevailing,  though  in  some  degree  modified.  He  directs  us  to 
let  the  woman  rest  a little  after  the  fatigues  of  the  birth,  unless  there  be  danger  of  haemor- 
rhage, that  the  uterus  may,  in  contracting,  have  time  to  squeeze  and  separate  the  placenta 
from  its  inner  surface;”  then  turning  the  funis  round  two  fingers,  or  wrapping  it  in  a cloth, 
to  pull  gently  from  side  to  side,  desiring  the  woman  to  assist  our  endeavours  “by  straining 
as  if  she  were  at  stool,  blowing  forcibly  into  her  hand,  or  provoking  herself  to  retch,  by  thrust- 
ing her  finger  into  her  throat.”  If  by  these  methods  the  placenta  cannot  be  brought  away,  to 
introduce  the  hand  and  deliver  it,  (chap.  ii.  sect.  5.) 

Some  years  before  Hunter  commenced  practice,  Ruysch,  whose  name  is  justly  rendered 
famous  as  an  anatomist,  particularly  by  his  employment  of  wax  injections  to  aid  in  dissec- 
tion, had  been  appointed  President  of  the  Obstetric  College  at  Amsterdam,  and  was  empow- 
ered by  the  magistrates  to  regulate  the  practice  of  midwifery  in  that  city.  Numerous  cases 
having  come  within  his  knowledge,  illustrating  the  fatal  effects  consequent  on  the  barbarous  cus- 
tom of  that  age,  he  wrote  with  much  force  and  ingenuity  against  it,  forbidding  the  extraction  of 
the  placenta  in  any  case ; and  from  his  spirited  opposition  we  may  date  the  commencement  of 
the  present  improved  practice.  Ruysch  certainly  trusted  in  much  too  great  a degree  to  the 
unaided  efforts  of  Nature,  and  ran  into  the  opposite  extreme  from  the  custom  he  deprecated. 
(Advers.  Anat.  Dec.  Sec.,  sect,  x.)  Much  allowance  must,  however,  be  made  for  the  strength 
of  his  language,  and  his  universal  reliance  on  Nature’s  powers,  since  his  arguments  were  in- 
tended to  uproot  a most  pernicious  and  dangerous  practice;  and  they  must  be  regarded,  there- 
fore as  those  of  a partial  advocate.  Hunter,  induced  by  the  same  feelings,  and  having  wit- 
nessed the  same  kind  of  calamities,  adopted  the  system  Ruysch  was  so  powerfully  advocating; 
and  we  are  told  by  Denman,  (Loco  Proximd  Citato,)  on  the  authority  of  Dr.  Hunter  himself, 
that  after  much  thought  and  hesitation,  his  colleague  in  the  obstetric  department  of  the  Mid- 
dlesex Hospital,  Dr.  Sandys,  and  himself  agreed  to  leave  the  placenta  to  be  expelled  entirely 
by  nature,  without  attempting  to  render  any  assistance  whatever.  In  the  first  instance  in 
which  this  experiment  was  tried,  twenty-four  hours  elapsed  before  the  placenta  passed  ; but 
as  no  ill  consequences  followed,  the  trials  were  repeated;  and  it  soon  became  the  general 


364 


COMPLEX  LABOURS. 


attendant  on  profuse  floodings  always  before  our  mind,  we  do  not  hesitate 
to  remove  the  placenta  by  the  introduction  of  the  hand  into  the  uterus,  as 
soon  as  a discharge  occurs  to  such  an  extent  as  to  bring  the  patient’s  life 
into  the  least  peril : and  we  think  ourselves  warranted  also  in  abstracting 
it  by  the  same  means,  provided  it  is  not  expelled  within  a limited  period. 
The  time,  therefore,  that  we  are  to  wait  before  proceeding  to  withdraw 
it,  becomes  a matter  for  our  consideration  of  deep  interest ; and  I cannot 
help  thinking  that  four  hours,  as  advised  by  Hunter  and  Denman,*  will  in 
general  be  found  too  long.  In  my  own  practice,  provided  there  is  no 
haemorrhage,  I am  generally  in  the  habit  of  delaying  operating  for  an  hour 
or  an  hour  and  a half  after  the  child’s  birth ; and  I consider  it  most  pro- 
bable, that  if  the  placenta  be  not  expelled  into  the  vaginal  cavity  at  the 
expiration  of  that  period,  and  there  be  not  more  than  the  usual  discharge, 
it  will  almost  always  be  found  extensively  adherent  to  the  uterine  struc- 
ture; for  if  morbid  adhesion  does  not  exist,  we  may  expect  that  the  mass 
will  be  separated,  and  haemorrhage  will  necessarily  result.  Should  this 
prove  the  case,  then,  it  is  most  likely  that  every  hour’s  delay  will  increase 
the  strength  of  the  uterine  contractions  around  the  placental  body,  and 
consequently  add  to  the  difficulties  which  will  beset  us  in  our  endeavours 
to  remove  it. 

Still,  however,  under  these  circumstances  time  must  not  entirely  guide 
us,  nor  its  lapse  be  our  only  indication  for  the  removal.  The  state  of  the 
uterine  contractions  must  not  be  overlooked.  Should  the  womb  be  acting 
powerfully  and  vigorously,  I should  be  induced  to  abstract  the  placenta 
earlier  than  the  specified  period,  under  the  belief  that  adhesion  had  taken 
place,  or  that  irregular  contraction  in  the  uterine  fibres  was  the  cause  of 
its  being  retained,  and  that  nature  would  not  be  able  to  surmount  the  dif- 
ficulties of  the  case  unaided  ; while,  on  the  other  hand,  if  the  uterus  re- 
mained inactive  and  sluggish,  I might  be  inclined  to  delay  longer,  provided 
there  was  no  alarming  discharge,  in  the  hope  and  expectation  that  it 
would,  after  the  lapse  of  a little  more  time,  resume  its  expulsive  action, 
and  that  the  case  would  be  terminated  without  manual  assistance ; and 
this  particularly  if  the  contractions  during  the  birth  of  the  child  had  been 
feeble,  or  the  labour  lingering.  I feel  convinced,  that  in  the  majority  dt 
those  instances  where  the  placenta  has  been  naturally  expelled  after  a re- 

rule  in  that  establishment  to  leave  the  expulsion  of  the  mass  to  Nature’s  unassisted  powers. 
The  occurrence,  however  of  some  fatal  cases  induced  Dr.  Hunter  to  modify  his  treatment; 
and  it  is  well  known  that,  before  his  death,  he  was  in  the  habit  of  removing  the  placenta  by 
the  hand  if  flooding  supervened ; and  I believe  he  also  recommended  its  withdrawal  at  the; 
expiration  of  four  hours  from  the  child’s  birth,  if  it  had  not  previously  passed,  although  there 
might  be  no  haemorrhage. 

* Introduction  to  Midwifery,  chap.  xv.  sect.  9. 


RETAINED  PLACENTA. 


365 


tention  of  many  hours,  it  has  been  lodging  the  principal  part  of  the  time 
in  the  vagina,  totally  excluded  from  the  uterine  cavity ; and  this  I think 
very  likely  to  have  happened  in  the  case  related  to  have  occurred  under 
Dr.  Hunter’s  superintendence,  because  the  principle  on  which  it  was  con- 
ducted was  that  of  perfect  non-interference. 

Absorption  of  the  Placenta. — Cases  are  on  record  in  which  the  pla- 
centa never  passed  from  the  uterus ; it  having  been  supposed  that  the 
whole  or  the  greater  part  of  it  had  been  absorbed  by  the  action  of  the  ute- 
rine vessels ; — and  some  practitioners  are  strong  advocates  for  ascribing 
to  the  uterus  the  power  of  absorbing  portions  of  placenta,  when  left  after 
the  child’s  birth.*  Knowing  the  astonishing  resources  which  Nature  pos- 
sesses, and  the  wonderful  contrivances  she  adopts  for  the  purpose  of  re- 
storing the  system  to  a healthy  state,  we  should  scarcely  have  the  teme- 
rity to  deny  the  possibility  of  such  an  occurrence,  even  were  it  not  con- 
tended for  by  respectable  authority  ; but  we  should  certainly  not  expect 
that  the  placental  mass,  or  any  great  proportion  of  it,  would  be  removed 
by  such  means ; and  we  should  be  acting  most  unwisely  if  we  were  in- 
duced by  that  hope  to  leave  it  in  the  uterus,  without  making  efforts  to  ex- 
tract it.f 


* Niiegele  entertains  this  opinion  ; (see  a communication  by  Merriman  in  Med.  Gaz.  vol.  iii. 
p.  189,  of  part  of  a paper  furnished  by  N&egele  to  Dr.  Von  Froriep’s  periodical,  “Notizen  aus 
dcm  Gebiethe  der  Natur  und  Heilkunde,”  where  four  instances  of  permanent  retention  of  the 
whole  placenta  and  one  of  a part  are  recorded.)  So  does  Prof.  Salomon  of  Leyden ; see  Rigby’s 
Mid.  Reports,  Med.  Gazette,  vol.  xiv.  p.  334.  Two  instances  are  there  mentioned,  in  which 
no  part  of  the  placenta  at  full  time  ever  passed  away.  One  related  by  the  late  Dr.  Young  of 
Edinburgh,  the  other  by  Prof.  Salomon.  Dr.  Rigby  follows  Naegele  in  this,  as  in  most  other 
of  that  distinguished  physician’s  views.  Velpeau  cites  three  cases  which  he  had  seen,  where 
after  abortion  the  placenta  did  not  come  away  ; he  thinks  these  were  absorbed,  and  seems  in- 
dined  to  believe  in  the  possibility  of  the  same  process  taking  place  after  delivery  at  full  time. 
(Traite  des  Accouch.  Art.  Resorption  du  Delivre.)  To  this  work  I would  refer  the  reader  for 
a notice  of  the  chief  number  of  well-attested  cases  of  this  description  on  record.  Ingleby  (on 
Uterine  Haemorrhage,  p.  206)  coincides  in  the  possibility  of  absorption;  but  supposes  that  the 
absorbent  vessels  themselves,  and  not  the  veins  of  the  uterus,  are  the  agents  of  its  removal. 
On  the  other  hand,  Dr.  Rumsey,  in  an  inaugural  thesis,  published  in  1837,  combats  the  idea 
of  the  whole  or  any  portion  of  a disrupted  placenta  ever  being  absorbed : he  thinks  that  when 

• expelled  entire,  or  broken  down  by  putrefaction,  the  parts  left  behind  become  organized 
land  amalgamated  with  the  structure  of  the  womb  itself. 

t In  the  year  1829  I was  requested  to  visit  a young  woman,  on  the  sixth  day  after  delivery 
of  a first  child,  in  consequence  of  the  placenta  being  still  retained  in  utero.  I learned  from 
£he  gentleman  who  had  attended  the  case,  that  the  labour  had  been  lingering;  that  the  child 
at  full  time  was  born  dead ; that  the  funis  had  broken  from  the  placenta  soon  after  the  birth, 
jind  that  the  mass  had  never  come  away ; but  that  there  had  been  no  heemorrhage.  I found 
,£fre  uterus  painful,  and  considerably  larger  than  it  should  have  been,  had  the  cavity  been 
-j&fhpty  ; the  discharge  from  the  vagina  was  scanty,  and  slightly  putrid.  The  os  uteri  was  al- 
most closed,  and  I could  feel  no  part  of  the  placenta.  She  was  suffering  under  a slight  degree 
of  fever ; but  there  were  no  urgent  symptoms  of  immediate  danger.  Two  days  afterwards 


366 


COMPLEX  LABOURS. 


Retention  of  the  Placenta. — The  placenta  may  be  unduly  retained  in 
utero  by  three  different  causes,  each  acting  separately,  or  two  in  concert. 
They  ar e,  first,  atony  of  the  uterus;  secondly , spasmodic  or  irregular  con- 
traction of  the  uterine  fibres;  and  thirdly , morbid  adhesion  having  taken 
place  between  the  placental  and  the  uterine  surfaces.* 

Retention  from  atony  of  the  uterus. — It  is  generally  observed,  that 
when  a want  of  due  and  sufficient  energy  on  the  part  of  the  uterus  pre- 
vents the  proper  contraction  of  its  fibres,  for  the  purpose  of  expelling  the 
placenta,  the  occurrence  takes  place  in  cases  where  the  woman  has  had 
a number  of  children — where  the  uterus  has  been  acting  feebly  during  the 
previous  stages  of  the  labour — where  a long  interval  has  occurred  between 
the  expulsion  of  the  head  and  the  passage  of  the  shoulders : after  linger- 
ing labours  also ; and  in  cases  where  the  patient  has  been  delivered  b) 
instrumental  aid,  in  which  the  uterus  has  become  worn  out,  and  the 
powers  of  life  much  depressed.  It  is  equally  likely  to  happen  if,  wher 
the  head  is  expelled,  the  attendant  has  suddenly,  forcibly,  and  improperly 
extracted  the  foetal  body  from  the  uterine  cavity ; after  which  reprehensi- 
ble interference  the  womb  is  left  in  a flabby,  relaxed,  and  torpid  state 
disinclined  to  continue  its  active  contractile  efforts  for  the  expulsion  o. 
the  placental  mass. 

We  may  know  that  the  placenta  is  in  utero  by  observing,  on  the  appli- 
cation of  the  hand  externally,  that  the  organ  is  larger  than  it  should  be  i 
emptied ; and  by  feeling  that  no  part  of  the  placenta,  or  only  a smal 
portion  of  it,  is  protruded  into  the  vagina.  But  do  we  know  why  it  is 
retained  in  the  uterus? — Can  we  tell  which  of  the  three  causes  I havt 
mentioned  is  in  operation? — We  cannot  discriminate  'positively,  excep 
under  the  introduction  of  the  hand  into  the  cavity  itself ; but  our  suspicion | 
as  to  the  true  cause  may  be  strong,  and  probably  correct.  We  ma\ 
presume  that  atony  is  the  cause,  if,  after  the  birth  of  the  child,  the  uteru* 
remains  soft,  large,  and  flabby  ; if  there  be  no  after-pains ; if,  when  w> 
take  hold  of  the  funis— and  this  is  a good  indication — we  find  that  the 
vein  is  not  full,  that  it  is  quite  flaccid ; because,  if  the  placental  mass  be 
squeezed  by  the  uterus  contracting  upon  it,  the  blood  will  be  forced  dowr 

she  appeared  much  in  the  same  state.  My  friend  watched  her  narrowly  for  more  than  a 
month,  during  which  time  a portion  of  placenta,  the  size  of  a walnut,  was  expelled.  She  re- 
covered her  health  perfectly,  and  returned  to  her  friends,  whom  she  had  been  obliged  by  cir- 
cumstances to  leave,  in  about  six  weeks.  I am  informed  that  nothing  more  passed  of  a solid 
character ; but  whether  she  ever  menstruated  after,  I do  not  know.  1 shall  not  enter  into  any 
speculations  on  the  case,  as  to  whether  absorption  may  have  taken  place,  or  what  change  may 
have  occurred  in  the  placenta  itself ; but  I place  every  reliance  on  the  statement,  that  so  long 
at  any  rate,  as  she  remained  under  my  friend’s  immediate  superintendence,  the  placental  mass 
did  not  escape  from  the  vagina. 

* Adhesion  may  exist  in  combination  with  atony,  and  also  with  spasmodic  contraction. 


RETAINED  PLACENTA. 


367 


from  the  placenta  into  the  cord,  under  which  action  the  arteries  and  vein 
become  turgid  and  distended  ; and  we  may  frequently  observe  it  twist  in 
a trifling  degree,  or  writhe  spontaneously,  somewhat  like  an  eel,  as  often 
as  a fresh  contraction  occurs  in  the  uterine  parietes.  This  twisting  is 
produced  by  the  blood  passing  gradually  downwards  along  the  vessels, 
which  are  seldom  straight,  but  almost  invariably  follow  a spiral  course, 
and  being  prevented  escaping  by  the  ligature  binding  their  cut  extremi- 
ties. 

Where  the  placenta  is  retained  by  atony  of  the  uterine  fibres,  the  blood 
is  generally  speaking,  poured  out  in  a copious  stream,  provided  any  por- 
tion of  the  organ  be  separated  from  its  previous  attachment ; because  the 
uterus  being  uncontracted,  its  vessels  continue  large ; and  their  open 
orifices  are  not  plugged  in  the  least  degree,  as  occurs  when  the  womb  has 
closed  itself  strongly  around  the  mass  retained  within  its  cavity. 

Treatment . — What  method,  then,  shall  we  adopt  under  this  state? — 
Are  we  to  remove  the  placenta  immediately  haemorrhage  shows  itself  by 
introducing  the  hand  into  the  cavity  of  the  womb ; or  can  we  stimulate 
the  uterus  to  contraction,  so  as  to  induce  it  to  throw  off  the  mass  without 
the  necessity  of  so  harsh  a proceeding  ? — By  pressure,  friction,  and  the 
application  of  cold,  we  may  frequently  excite  such  efficient  action  that 
the  placenta  will  gradually  descend  into  the  vagina,  and  the  introduction 
of  the  hand  be  rendered  unnecessary.  But  we  must  always  bear  in  mind, 
that  these  means  ought  not  to  be  trusted  to  exclusively  and  entirely, 
under  a continuance  of  copious  discharge;  and  that  frequently  the  manual 
removal  of  the  placenta  from  the  uterine  cavity  itself,  will  alone  check 
the  flow,  and  place  the  patient  in  a state  of  safety. 

If,  under  a retention  of  the  placenta  from  atony  of  the  uterine  structure, 
there  be  little  or  no  sanguineous  appearance,  and  no  disposition  to  faint- 
ness supervene,  fifteen  or  twenty  minutes  may  be  allowed  to  pass  without 
any  artificial  means  being  used  to  solicit  the  renewal  of  uterine  action. 
On  the  expiration  of  such  a period,  pressure  may  be  applied  to  the  uterus 
by  the  hand  placed  externally ; or  gentle  friction  may  be  made  over  the 
hypogastric  region.  Should  an  unusual  discharge  of  blood  now  take 
place,  cloths  dipped  in  cold  vinegar  and  water  may  be  suddenly  laid  upon 
the  lower  part  of  the  abdomen  and  the  vulva,  and  the  pressure  and  fric- 
tion persevered  in;  and  should  the  discharge  continue  to  an  alarming 
extent,  or  increase  to  a profuse  haemorrhage,  the  removal  of  the  placenta 
must  at  once  be  undertaken.  All  other  considerations  must  give  way  to 
procuring  an  emptied  and  contracted  state  of  uterus;  and  that  can  only 
with  certainty  be  accomplished  by  the  withdrawal  of  the  placenta. 
Many  a woman  has  fallen  a victim  to  the  timidity  of  her  attendant ; many 
a life  has  been  sacrificed  by  the  trial  of  trifling  means,  perfectly  inade 


368 


COMPLEX  LABOURS. 


quate  to  the  production  of  the  grand  end  proposed — the  contraction  of  the 
uterine  parietes,  the  evacuation  of  its  cavity,  and  the  perfect  closure  of  it! 
vessels.  I should  have  but  little  faith  in  the  efficacy  of  cold  water  injectec 
into  the  uterus,  while  the  placenta  was  retained  in  the  cavity,  althougl 
strongly  recommended  by  Gooch.*  It  may  be  useful  in  floodings,  afte: 
the  placenta  is  expelled,  but  even  then  can  by  no  means  generally  be  re 
sorted  to,  because  the  necessary  implements  may  not  be  at  hand.  And 
should  bave  still  less  faith  in  emptying  the  umbilical  vessels  of  their  blood 
with  the  hope  of  diminishing  the  size  of  the  placenta,  as  suggested  b; 
some  physicians  ;f  or  in  injecting  the  umbilical  vein  with  cold  water,; 
diluted  vinegar, § or  brandy, ||  or  any  astringents,  as  practised  by  others 
the  great  objections  to  all  these  measures  being,  that  while  we  are  employing 
them,  the  blood  may  be  gushing  from  the  uterus,  and  the  patient  is  dying 
that  we  are  uncertain  whether  morbid  adhesion  may  not  exist  at  the  sam 
time,  in  conjunction  with  deficient  energy  in  the  uterine  fibres,  which  ma; 
eventually  require  manual  separation ; and  that  the  introduction  of  th 
hand  is  the  strongest  provocative  to  uterine  action  of  any  means  we  ca; 
resort  to.  The  same  objections  apply  to  throwing  purgative  clysters  int 
the  rectum,  as  noticed  by  Blundell  as  well  as  to  the  use  of  the  ergot 
which,  although  it  have  the  power  of  exciting  contraction  in  the  uterin 
fibres,  requires  some  time  for  the  establishment  of  its  action  ; and,  if  th 
placenta  were  at  all  firmly  adherent,  must  fail  in  bringing  about  its  expul 
sion.  « 

When  the  necessity,  then,  for  the  removal  of  the  placenta  is  apparent 
and  we  dare  no  longer  trust  to  more  mild  and  less  powerful  agents,  th 
operation  must  be  undertaken  in  the  following  manner : — 

The  patient  lying  on  her  left  side,  conveniently  near  the  edge  of  th 
bed,,  we  must  take  off  our  coat — as  in  all  cases  where  it  becomes  neces 
sary  to  introduce  the  hand  into  the  uterus ; — denude  the  left  arm  and  grea$ 
it  ;**  then  kneeling  down  by  the  bed-side,  we  bring  the  fingers  into  th 
form  of  a cone,  twist  the  funis  umbilicalis  two  or  three  times  round  th 
first  and  second  fingers  of  the  right  hand,  to  give  us  a guide  to  the  placenta 
and  quietly  insinuate  the  left  into  the  uterus.  There  is  little  or  no  diff 
culty  in  passing  it  through  the  external  parts,  vagina  and  os  uteri,  if  th 
operation  be  undertaken  within  an  hour  or  two  of  the  child’s  birth ; nor  i 
there  any  difficulty  in  introducing  it  fully  into  the  uterine  cavity,  becaus 

* Compendium  by  Skinner,  p.  172.  t See  page  133,  note, 

t Taroni;  Rev.  Med.,  Sept.  1827. 

§ Mojon;  Nuevo  Mezzo  di  Estraere  la  Placenta,  &c.,  1825. 

H Hoffman ; Ann.  Univers.,  Juin,  1827.  IT  Obstetricy,  by  Castle,  p.  616, 

**  Hamilton  (Pract.  Ob?.,  p.  171)  strongly  recommends  the  right  hand  to  be  used  for  tt 
removal  of  the  placenta  from  the  uterus ; as  do  other  practitioners. 


RETAINED  PLACENTA. 


369 


the  parietes  are  in  a flaccid  condition,  and  the  cavity  itself  is  both  consi- 
derably distended,  and  readily  dilatable. 

The  removal  of  a placenta  from  the  uterus,  indeed,  retained  by  simple 
inertia,  is  one  of  the  easiest  operations  in  surgery ; but  the  condition  re- 
quiring its  adoption  is  of  a highly  dangerous  character ; and  the  danger 
will  be  in  proportion  to  the  facility  with  which  the  organ  admits  the  hand. 
The  danger,  then,  is  not  that  we  should  bruise  or  lacerate  its  structure,  or 
dispose  it  to  inflammatory  disease,  but  that  we  should  leave  it  in  an  un- 
contracted state  after  the  withdrawal  of  the  placenta,  and  consequently 
subject  the  woman  to  a continuance  of  the  haemorrhage.  It  certainly  far 
more  frequently  happens,  that  the  stimulus  of  the  hand  causes  the  uterus 
to  act,  and  that  in  contracting  it  expels  the  hand  and  placenta  together; 
and  this  is  a fortunate  occurrence ; it  is  to  be  hailed  as  the  best  proof  of 
safety. 

Whenever  we  are  compelled  to  resort  to  manual  extraction,  we  must 
bear  in  mind,  that  previously  to  the  introduction  of  the  hand,  we  cannot 
tell  in  what  situation  we  may  find  the  placenta ; it  may  be  entirely  thrown 
off  from  the  uterine  surface,  and  lying  loose  in  the  cavity ; or  it  may  be 
partly  separated,  and  partly  attached;  or  it  may  be  partially,  or  through 
its  whole  extent,  morbidly  adherent.  For  these  reasons  we  must  not 
always  calculate  on  meeting  with  so  easy  a case  as  I have  just  described; 
we  must  not  suppose  that  all  we  have  to  do  is  to  introduce  the  hand  and 
draw  out  the  placenta.  If  we  act  in  this  way,  we  may  find  the  case  much 
more  difficult  than  we  expected ; we  may  lose  our  presence  of  mind ; we 
may  withdraw  our  hand  in  doubt  and  disappointment,  cause  a serious 
aggravation  of  the  flooding,  and  increase  the  previous  peril.  Let  us,  then, 
before  operating,  make  up  our  mind  to  have  to  encounter  the  most  difficult 
of  all  the  cases  of  retained  placenta  which  can  possibly  occur;  and  should 
we  find  it  more  easily  managed  than  we  anticipated,  our  error,  if  it  be 
one,  is  on  the  right  side. 

1 will  suppose  that  it  is  partly  attached,  but  not  morbidly  adherent. 
We  pass  the  left  hand  gently  into  the  uterus,  guided  by  the  funis;  and  on 
its  introduction  place  the  right  hand  between  the  woman’s  thighs  on  the 
abdomen,  to  steady  the  uterine  tumour  externally ; for  that  organ  being  so 
much  smaller  than  it  was  before  the  birth  of  the  child,  the  parietes  of  the 
abdomen  do  not  support  it,  but  it  rolls  about  in  the  abdominal  cavity 
impeding  our  endeavours  to  remove  the  mass.  When  the  hand  has  fully 
gained  possession  of  the  cavity,  we  tear  the  membranes  with  our  fibers 
and  passing  them  between  the  placental  and  uterine  surfaces,  run  our 
hand  all  over  the  maternal  face  of  the  placenta,  to  be  assured  that  we 
have  got  the  whole  organ  within  it,  grasp  the  uterus  externally  with  the 
right;  and  it  is  most  probable  that,  from  the  double  stimulus  thus  applied, 


370 


COMPLEX  LABOURS. 


— that  of  irritation  within,  and  compression  externally, — a contraction  will 
occur;  we  may  then  quietly  withdraw  our  hand,  retaining  the  placenta 
within  its  hold.  Should,  however,  this  desirable  action  not  supervene,  we 
may  keep  the  hand  a short  space  within  the  cavity,  and  endeavour  to  en- 
sure contraction,  by  gently  moving  our  fingers,  so  as  to  irritate  the  parietes 
in  some  trifling  degree. 

On  the  entire  withdrawal  of  the  mass — whatever  may  have  been  the 
cause  obliging  us  to  have  recourse  to  its  removal  manually — we  must 
never  forget  to  examine  whether  or  not  it  be  entire ; for  it  is  possible  that 
the  whole  may  not  have  been  extracted.  It  is  not  unlikely  that  adhesion 
may  have  taken  place  between  a portion  of  its  structure  and  the  uterus 
itself;  that  instead  of  passing  the  hand  over  its  whole  face,  we  may  have 
broken  it,  and  brought  away  only  a part,  leaving  the  remainder  in  the 
uterine  cavity.  To  assure  ourselves  that  we  have  removed  it  all,  we  must 
lay  it  upon  a napkin,  with  the  maternal  face  upwards.  If  there  be  a large 
portion  wanting,  we  cannot  be  deceived ; we  observe  that  the  mass  is 
broken,  and  we  see  the  cavity  from  which  a piece  has  been  separated.* 
If,  then,  we  find  that  a third,  or  a quarter,  or  any  other  large  quantity  be 
missing,  we  should  immediately  introduce  the  hand  a second  time;  for  it 
is  much  better  to  remove  the  disruptured  portion  than  to  leave  it  to  be 
thrown  off  by  Nature.  This  should  be  done  before  the  uterus  is  com 
tracted  around  it;  and  if  much  difficulty  be  experienced,  we  must  desist 
from  our  attempts.  But  if  there  be  only  a number  of  small  filaments  left* 
it  would  be  injudicious  to  make  any  exertion  for  their  removal;  since  we 
must  put  the  patient  to  much  pain,  run  the  risk  of  doing  permanent  injury; 
and  in  the  end,  most  likely,  not  accomplish  our  object. 

Retention  from  irregular  contraction. — The  second  cause  of  retention 
is  irregular  contraction  in  the  uterine  fibres.  This  generally  happens  after 
the  uterus  has  acted  violently,  when  the  child  has  been  very  rapidly  exi 

* From  the  neglect  of  this  very  simple  proceeding,  I have  known  many  cases  of  great  dan- 
gcr  occur.  A medical  friend  called  me  to  his  assistance  on  the  appearance  of  violent  haemor- 
rhage, after,  as  he  believed,  the  placenta  was  removed.  Immediately  I placed  my  hand  on 
the  abdomen,  I felt  satisfied  that  the  whole,  or  principal  part  of  it,  was  still  within  the  uterus  ; 
but,  on  inquiry,  was  informed  that  it  had  come  away  on  the  application  of  the  slightest  trac- 
tion possible.  On  requesting  to  inspect  it,  an  utensil  was  brought  which  it  was  supposed  con- 
tained the  placenta.  There  was  the  funis  entire— there  were  all  the  membranes— and  there 
was  a large  mass  that  looked  like  the  placenta  lying  below  the  membranes.  On  turning  it 
up,  however,  no  part  of  the  placenta  was  there.  The  cord  and  membranes  had  slipped  away 
from  their  attachment  to  its  body,  and  a large  quantity  of  blood  had  collected  within  the 
membranes  and  there  coagulated,  which  was  mistaken  for  the  placenta  itself.  If,  instead  oi 
being  satisfied  with  the  appearance  of  the  funis  and  foetal  membranes,  my  friend  had  made 
his  examination,  as  I have  just  recommended,  the  mistake  could  not  have  happened  ; and  the 
cause  of  the  continuance  of  the  hcemorrhage  would  have  been  at  once  apparent.  For  n case 
almost  precisely  similar,  Velpeau,  (edit.  Bruxelles,  p.  309,)  may  be  consulted. 


RETAINED  PLACENTA. 


371 


pelled,  its  whole  body  being  projected  forth  probably  by  one  pain,  and 
under  the  same  action  the  organ  has  contracted  strongly  around  the  pla- 
centa ; or  where  improper  attempts  have  been  made  to  remove  it  from  the 
uterine  cavity  by  pulling  and  jerking  at  the  funis.  In  this  case,  then,  either 
all  the  fibres  shorten  themselves  simultaneously,  or  some  are  in  a con- 
tracted state  while  others  are  dilated;  ihstead  of  the  action  being  regularly 
progressive  from  the  fundus  downwards.  Upon  this  occurrence  taking 
place,  two  or  three  strong  pains  will  generally  follow  each  other  in  rapid 
succession,  soon  after  the  expulsion  of  the  child ; and  sometimes  they  are 
almost  as  severe  as  those  experienced  before  the  perfection  of  the  birth. 
If  the  uterus  act  strongly  in  this  way,  while  the  placenta  does  not  descend 
within  reach  of  the  finger,  if  the  funis  umbilicalis  become  full  and  turgid 
with  blood,  and  if  the  uterus  feel  very  hard,  as  well  as  large,  to  the  hand 
externally  applied,  these  symptoms  are  suspicious  of  the  state  I am  de- 
scribing. Generally  speaking,  under  these  cases  there  is  not  such  violent 
haemorrhage  as  when  atony  is  the  cause  of  delay ; and  some  time  may 
frequently  elapse  without  there  being  such  a degree  of  flooding  as  would 
induce  us  to  remove  the  placenta. 

Let  us,  however,  not  wait  longer  than  the  limit  before  assigned — one 
hour  and  a half,  and  in  the  mean  time  we  may  consider  whether  we  can, 
by  any  internal  medicines  or  outward  applications,  overcome  the  spas- 
modic state.  External  means  seem  of  little  service,  and  of  all  medicines, 
opium,  perhaps,  is  the  only  one  which  can  procure  the  relaxation  sought. 
It  is,  indeed,  very  generally  recommended  under  this  state.  Opium  in 
moderate  quantities  I should  not  object  to ; but  I have  a decided  aversion 
to  its  employment  in  large  doses ; because  its  influence  may  be  greater 
than  we  anticipated — the  opposite  condition  to  that  previously  existing 
may  be  produced;  the  uterine  powers  may  be  paralyzed;  and,  although 
the  difficulty  in  the  removal  of  the  placenta  may  vanish,  the  contractions 
necessary  for  the  ultimate  safety  of  the  woman  may  never  be  resumed. 
Again : it  is  more  than  probable  that  adhesion  may  co-exist  with  this  irre- 
gular action ; and  if  such  be  the  case,  the  introduction  of  the  hand  will 
eventually  be  required.  Still  greater  objections  apply  to  the  abstraction 
•of  blood  by  the  lancet,  for  the  purpose  of  relaxing  this  spasmodic  contrac- 
tion— a means  which  has  occasionally  been  resorted  to  ;*  but  which  I 
should  strongly  deprecate,  even  although  there  might  be  no  flooding ; for 

* Gardien  (tom.  iii.  p.  256)  recommends  bleeding  in  conjunction  with  other  means,  before 
jth  attempt  is  made  to  remove  the  placenta  manually.  Blundell  (Obstetricy,  p.  625)  thinks 
some  few  cases  might  justify  the  use  of  the  lancet;  and  stales  that  he  has  abstracted  sixteen  or 
twenty  ounces  of  blood  with  the  view  of  producing  relaxation.  Ingleby  (Ut«  Heemor.,  p 
198)  says,  “ this  measure  will  rarely  be  found  admissible,  except  in  the  instances  of  plethoric 
women,  and  in  the  absence  of  haemorrhage.” 


372 


COMPLEX  LABOURS. 


I should  dread  the  probability  of  a copious  discharge  from  the  uterus,  so 
long  as  that  organ  remained  unemptied  and  uncontracted.  Should  apoplexy 
or  convulsions,  indeed,  occur  immediately  on  the  child’s  expulsion,  bleeding 
would  be  indicated,  and  it  might  be  highly  proper  to  open  a vein,  even 
before  any  part  of  the  placenta  passed  into  the  vagina;  but  I am  now 
speaking  of  venesection  as  a means  of  overcoming  that  spasmodic  state  of 
the  uterus  which  prevents  the  placenta  descending. 

On  the  other  hand,  I should  equally  object  to  the  use  of  those  means 
which  will  increase  the  tone  of  the  uterus — such  as  the  ergot  of  rye. 
In  my  own  practice,  indeed,  I am  in  the  habit  of  relying  only  on  the 
careful  removal  of  the  placenta  by  manual  operation ; — the  indications 
being  lapse  of  time  on  the  one  hand,  and  flooding  on  the  other. 

Irregular  contraction  is  of  various  kinds.  Sometimes  the  uterus  con- 
tracts globularly  on  the  placenta,  Plate,  XLIX.  fig.  135,  sometimes  longi- 
tudinally, assuming  somewhat  the  shape  of  a sugar-loaf ; at  others,  it 
contracts  with  a corner,  fig.  136,  so  that  in  one  part  or  other  there  is  a 
sac,  in  which  the  principal  bulk  of  the  placenta  is  retained;  the  other 
portions  of  the  organ  being  in  a relaxed  state.  Sometimes  it  contracts 
with  a sharp  ridge  anteriorly,  something  like  a hog’s  back ; but  this  is 
rare.  At  others,  again,  the  central  fibres  of  the  body  of  the  uterus  act 
powerfully,  leaving  those  of  the  fundus  and  neck  uncontracted,  and  the 
hour-glass  state  is  produced;  fig.  137;  the  placenta  being  prevented  from 
descending,  by  the  constricted  ring  formed  by  the  circular  fibres  of  the 
body.* 


* We  hear  much  of  hour-glass  contraction  of  the  uterus,  but  my  belief  is,  that  there  is  no 
rater  case  in  midwifery  than  the  real  and  true  hour-glass  contraction,  such  as  I have  described. 
Professor  Burns,  indeed,  states,  that  “ in  almost  every  instance  this  contraction  takes  place  ; ; 
that  he  scarcely  ever  introduced  his  hand  into  the  uterus,  in  a case  of  flooding,  without  meet- 
ing with  it,  whether  the  placenta  had  or  had  not  been  expelled.” — (Princip.  of  Mid.,  5th  edit.,1 
p.  485.)  Burns’  authority  is  great  on  all  subjects  connected  with  the  obstetric  department  of 
medicine,  but  in  this  sentiment  I can  by  no  means  concur ; and  I am  certainly  not  singular 
in  my  opinion ; for  Ingleby  (Op.  Cit.,  p.  192)  looks  upon  this  case  as  of  “ very  rare  occur- 
rence,”  Blundell  (Obstetricy,  p.  623)  says  “ it  does  not  happen  so  often  as  many  imagine,” 
and  other  practical  men  have  expressed  themselves  in  similar  terms.  I can  scarcely  suppose 
the  Professor  himself  could  be  mistaken,  and  presume  (although  this  does  not  appear  from  his 
writings)  that  he  and  I do  not  apply  exactly  the  same  meaning  to  the  term  “ hour-glass  con- 
traction;” but  I am  almost  persuaded  that  the  general  idea  of  the  occurrence  being  so  frequent, 
has  its  origin  in  error  : — that  the  contraction  of  the  uterus,  indeed,  is  of  the  globular  kind ; 
that  its  whole  cavity  is  considered  the  upper  chamber ; the  os  uteri  being  taken  for  the  con- 
striction of  the  central  fibres  of  the  body,  and  the  dilated  vagina, — having  in  it  a coagulum  of 
blood, — for  the  lower  chamber.  In  many  cases  I have  been  told  that  an  hour-glass  contrac- 
tion existed,  but,  when  I came  to  examine  for  myself,  I found  it  was  of  a mere  simple  globular 
kind.  Out  of  a very  large  number  of  instances,  in  which  I have  been  called  upon  to  remove 
the  placenta,  I do  not  recollect  to  have  met  with  more  than  three  or  four  that  perfectly  agreed 
with  my  idea,  of  the  true  hour  glass  contraction.  Some  practitioners,  again,  consider  that 


Sirtc2aJi'  sJjit'h-. 


RETAINED  PLACENTA. 


373 


There  is  less  danger  of  flooding  in  irregular  contraction  than  when  the 
uterus  is  in  a state  of  atony,  but  the  operation  of  removal  is  both  more 
dangerous  and  difficult,  because  of  the  resistance  necessary  to  be  over- 
come : and  in  proportion  to  the  strength  of  the  spasm  will  be  the  proba- 
bility of  injury. 

Treatment. — Since,  then,  there  is  so  much  more  chance  of  injuring  the 
uterus,  it  behoves  us  to  be  so  much  the  more  cautious  in  our  proceedings. 
If  there  be  no  flooding,  we  may  generally  wait  an  hour  from  the  birth  of 
the  child ; and  in  the  interval,  we  may  administer  small  doses  of  lauda- 
num occasionally ; but  if  hsemorrhage  come  on,  we  should  not  perform 
our  duty,  did  we  delay  the  employment  of  more  active  means  a single 
minute.  We  must,  then,  make  up  our  minds  to  meet  with  a certain 
degree  of  resistance,  and  we  must  overcome  it  in  the  softest  and  most 
gentle  manner.  Having  taken  off  our  coat  and  anointed  our  hand  and 
arm,  we  kneel  by  the  bed-side  and  introduce  our  hand,  previously  gathered 
into  the  form  of  a cone,  fully  into  the  vagina.  When  we  arrive  at  the 
os  uteri,  we  must  dilate  it  with  the  greatest  care,  using  a slow  boring 
motion,  and  steadying  at  the  same  time  the  uterine  tumour  with  the  right 
hand  externally  applied.  The  hand  having  entered  the  cavity,  must  be 
passed  behind  the  placenta,  between  its  maternal  face  and  the  uterus,  as 
before  directed ; it  must  be  carried  over  the  whole  surface  of  the  mass,  to 
ascertain  that  no  part  remains  adherent,  and  when  we  have  embraced 
it  all  within  our  grasp,  it  may  be  withdrawn.  The  uterus  will  most  pro- 
bably act  forcibly,  on  the  introduction  of  the  hand  into  its  cavity,  and 
after  the  separation  is  effected,  will  expel  it  and  the  placenta  together. 

It  might  be  supposed  that  cases  will  occasionally  happen  in  which  we 
cannot  introduce  the  hand  for  the  removal  of  the  placenta  after  the  child’s 
birth.  It  is  possible,  certainly,  that  the  uterus  may  take  upon  itself  such 
violent  contraction  immediately,  as  to  offer  an  insuperable  barrier  to  the 
passage  of  the  hand ; but  I never  met  wTith  a case  of  this  kind  when  the 
operation  had  not  been  deferred  much  beyond  the  limit  I have  assigned 
for  our  more  passive  treatment.  I never  saw  an  instance,  within  a few 
hours  after  the  birth,  in  which,  by  care,  tenderness,  and  perseverance,  I 


the  hour-glass  contraction  never  occurs;  and  that  therefore  the  idea  of  detention  of  the  placenta 
from  this  cause  is  entirely  hypothetical;  (see  a letter  by  Mr.  Moss  of  Eton,  Med.  Gazette,  vol. 
vi.  p.  172;  also  another  by  Sir  John  Chapman  of  Windsor,  same  volume,  p.  400.)  Campbell 
(System  of  Mid.,  p.  205)  says,  “ he  never  met  with  hour-glass  contraction,  and  thinks  it  very 
rare,  or  that  it  does  not  exist  at  all.”  By  these  gentlemen  the  case  is  accounted  for  as  by 
myself.  In  a paper  published  in  vol.  vi.  of  the  Transactions  of  the  Royal  College  of  Physi- 
cians, Dr.  Douglas  of  Dublin  thinks  this  particular  kind  of  contraction  rarely  or  never  exists 
without  adhesion  of  the  placenta  to  the  uterine  surface ; and  I am  inclined  to  the  opinion,  that 
adhesion  is  generally  present,  not  only  with  the  hour-glass,  but  with  most  other  irregular 
contractions  also. 


374 


COMPLEX  LABOURS. 


could  not  introduce  my  hand,  and  that  without  injury  to  the  uterine  struc- 
ture, provided  the  term  of  gestation  were  nearly  completed.  Our  obvious 
indication,  if  we  were  foiled,  would  be  to  place  the  patient  in  some  degree 
under  the  influence  of  opium,  and  take  advantage  of  the  earliest  oppor- 
tunity of  its  action  to  renew  our  attempts:  for  the  longer  we  wait,  the 
more  difficulty  we  shall  experience  from  the  permanent  contraction  which 
will  assuredly  take  place,  and  which  we  have  no  means,  as  far  as  I have 
been  able  to  judge,  of  removing. 

Another  kind  of  irregular  contraction  sometimes  occurs — the  two  rapid 
closure  of  the  os  uteri  during  the  passage  of  the  placenta  through  it;  by  which 
action  the  mass  is  detained  prisoner,  lying  partly  in  utero,  partly  in  vagina . 
Any  attempt  to  draw  it  forth  by  pulling  at  its  edge  will  usually  be  fol- 
lowed by  a laceration  of  the  placenta  itself,  and  a cautious  dilatation  of 
the  orifice  is  generally  required  for  its  removal.* 

Retention  from  morbid  adhesion. — The  last  case  is  the  most  difficult  of 
all:  that  m which  morbid  adhesion  takes  place,— agglutination  between 
the  two  surfaces  of  the  uterus  and  placenta, — in  consequence,  most  pro- 
bably, of  a deposition  of  coagulable  lymph,  the  produce  of  a peculiar  kind 
of  inflammation  which  the  lining  membrane  of  the  uterus  has  taken  upon 
itself  during  pregnancy.f  The  adhesion  may  be  of  greater  or  less  extent, 


* See  Hamilton’s  Pract.  Obs„  1840,  p.  178,  This  case  I have  frequently  met  with. 

t Many  reasons  induce  me  to  believe  that  this  morbid  adhesion  is  produced  by  the  forma- 
tion  of  a fresh  membrane,  the  consequence  of  inflammatory  action  existing  in  the  uterus.  In 
the  first  place,  we  find  adhesion  of  the  placenta  more  frequent  among  the  lower  classes  than 
in  the  higher  circles;  and  this  is  easily  explained  upon  the  greater  liability  of  the  poor  to 
such  accidents  during  pregnancy  as  are  likely  to  induce  inflammation  in  the  uterine  structure, 
which  may  terminatp  in  the  agglutination  of  the  two  surfaces  together. 

I have  often  myself  known  adhesion  of  the  placenta  follow  an  injury  during  gestation;  and 
I have  frequently  inquired  of  my  patient  after  having  removed  an  adherent  placenta,  whether  ' 
she  has  suffered  pain  in  the  belly  during  pregnancy,  and  her  reply  has  very  usually  been, 

“ Yes,  just  where  your  hand  was,” — my  hand,  for  the  purpose  of  the  separation,  having  been 
carried  to  the  part  where  agglutination  had  taken  place.  From  observing,  then,  that  the 
patient,  while  pregnant,  has  had  a fall,  or  received  a blow;  that  she  has  experienced  pain,  evi- 
dently the  result  of  inflammation,— I think  that  there  is  no  doubt  that  the  morbid  union  is 
the  effect  of  the  same  kind  of  action  in  the  vessels  of  the  uterus  as  occasions  the  formation  of 
false  membranes  in  other  parts  of  the  body;  and  I see  no  reason  to  believe  otherwise.  I .do' 
not  mean  to  state  that  adhesion  will  be  met  with  in  every  case  where  pain  in  the  region  of  ‘ 
the  uterus  exists  during  gestation,  because  that  pain  may  be  spasmodic  or  neuralgic,  and  not 
the  effect  of  inflammatory  action ; besides,  the  whole  structure  of  the  organ  need  not  be  the  • 
subject  of  the  disease,  although  it  were  inflammatory  ; the  lining  membrane  may  possibly  - 
escape:  even  should  the  mucous  membrane  be  implicated,  the  affection  may  be  situated  in  a 
part  remote  from  the  implantation  of  the  placental  mass,  and  consequently  no  change  can  be  i 
expected  to  occur  at  that  particular  spot.  Again,  let  us  suppose  that  the  very  point  at  which  ! 
the  foetal  organ  is  attached  has  become  the  seat  of  injury  and  subsequent  inflammation,  still 
it  is  evident  that  resolution  may  occur,— that  effusion  of  lymph  need  not  take  place,  and  that- 


RETAINED  PLACENTA. 


375 


and  of  a higher  or  lower  degree  of  intensity.  Sometimes  the  whole 
placenta  becomes  united  by  adhesion,  of  which  1 have  known  instances ; 
at  others,  the  part  adherent  may  not  exceed  a sixpence  in  extent ; but  the 
union  may  be  so  firm  that  the  unaided  efforts  of  the  uterus,  however 
strongly  excited,  are  not  sufficient  to  produce  entire  separation  of  the 
mass.  Professor  Burns*  mentions  a case  in  which  the  placenta  was 
retained  four  days,  and  a fatal  termination  ensued,  although  the  surface 
morbidly  adherent  was  not  larger  than  a shilling. 

As  a general  principle,  the  larger  is  the  surface  detached  from  the  ute- 
rus the  more  copious  will  be  the  haemorrhage,  because  the  greater  is  the 
number  of  vessels  opened;  and  if  the  adhesion  be  entire,  the  sanguineous 
appearance  will  be  but  very  trifling;  no  blood  flowing,  indeed,  out  of  the 
vessels  in  connexion  with  the  placenta,  and  all  that  is  lost  being  afforded 
by  the  small  arteries  which  communicated  with  the  deciduous  membrane. 

Whenever  half  an  hour  or  an  hour  has  elapsed  since  the  birth,  without 
the  appearance  of  any  discharge,  while  at  the  same  time  three  or  four 
smart  uterine  contractions  have  taken  place,  we  may  begin  to  suspect  not 

no  difficulty  may  arise  in  the  labour ; so  that  there  are  a great  many  chances  against  the  pro- 
duction of  the  effect  I am  describing. 

My  belief,  however,  that  this  morbid  adhesion  is  caused  by  inflammation  of  the  lining  mem- 
brane of  the  uterus,  is  also  strengthened  by  having  observed  this  state  occasionally  follow 
accidental  haemorrhages  towards  the  close  of  pregnancy.  Cases  are  not  unfrequently  met 
with  in  which  two  or  three  eruptions  of  blood  having  taken  place,  consequent  on  some  exter- 
nal and  easily  assignable  cause,  the  haemorrhage  gradually  ceases,  and  does  not  return  ; but, 
under  labour,  adhesion  of  the  placenta  is  discovered. 

I presume,  under  such  circumstances,  that  the  cessation  of  the  discharge  depends  upon  an 
agglutination  of  that  portion  of  the  placenta,  previously  separated,  with  the  uterus : nor  is  the 
explanation  difficult.  The  two  surfaces  remain  in  contact,  though  not  attached,  having  been 
disunited  from  each  other  by  some  accidental  cause;  and  to  prevent  a continuance  of  bleeding, 
and  to  save  life,  Nature  makes  a strenuous  effort;  inflammation  is  set  up  in  the  membrane  of 
the  womb,  by  which  the  placenta  is  glued  to  the  uterine  surface,  and  thus  the  open  vessels  are 
permanently  closed.  Such  a change  is  not  more  extraordinary  than  many  of  the  contrivances 
to  avert  danger,  which  we  daily  observe  Nature  to  practise,  and  quite  in  accordance  with  the 
mode  she  generally  adopts  to  repair  injuries. 

Moreover,  I have  had  occasion  to  notice,  in  an  early  part  of  this  work,  that  disease  some- 
times takes  place  in  the  placenta  itself.  Occasionally  the  mass  becomes  studded  with  tuber- 
cular formations,  like  small  scirrhous  glands:  sometimes  there  are  spiculae  or  granules  of 
bone  strewed,  as  it  were,  over  the  maternal  surface,  and  sometimes  the  organ  becomes  almost 
cartilaginous  throughout;  at  others,  unnaturally  soft; — these  states  being  frequently  con- 
nected with  adhesion  under  labour.  It  is  fair  to  presume,  then,  that  the  uterine  membrane  is 
excited  and  irritated  by  contact  with  the  diseased  mass,  and  that  inflammation  is  the  primary, 
and  effusion  of  lymph  the  secondary,  effect. 

When  all  these  circumstances  are  considered  in  conjunction,  there  can  be  little  doubt  that 
the  morbid  change  occasioning  adhesion  of  the  placenta,  is  to  be  referred  to  excitement  of  the 
uterine  vessels  as  the  immediate  agents,  and  not  to  the  foetal  system. 

* Op.  Cit.,  p.  490. 


376 


COMPLEX  LABOURS. 


only  that  the  placenta  is  morbidly  adherent  but  that  throughout  its  whole 
extent ; because,  if  any  part  were  separated,  some  vessels  must  be  rendered 
patulous.  This  is  certainly  a rare  case,  but  it  has  happened  to  me  two  or 
three  times  to  meet  with  it. 

The  intensity  varies  in  degree  as  much  as  the  extent:  it  is  sometimes 
so  slight,  that,  notwithstanding  the  uterine  powers  cannot  accomplish  the 
expulsion  of  the  mass,  yet  it  may  be  separated  by  the  hand  with  the  great- 
est ease ; in  others  again,  the  adhesion  is  so  strong  that  it  is  impossible  to 
peel  it  off  from  its  attachment.  Instances  are  sometimes  met  with  in 
which  a portion  of  the  placenta  is  so  closely  attached  to  the  uterine  sur- 
face, that  it  cannot  by  any  means  be  removed ; nay,  I have  opened  more 
than  one  body  where  a part  was  left  adherent  to  the  uterus,  and  where, 
on  making  a longitudinal  section  of  the  organs,  and  examining  the  cut 
edges,  I could  not  determine  the  boundary  line  between  the  uterus  and  the 
placenta,  so  intimate  a union  had  taken  place  between  them  ;*  the  student 
may  readily  imagine,  therefore,  the  difficulty  which  must  sometimes  be 
experienced  in  attempting  to  remove  it  when  adherent. 

When  called  upon  to  separate  an  adherent  placenta,  we  may  find  the 
uterus  flabby  and  uncontracted,  or  it  may  have  embraced  the  mass  more 
or  less  tightly.  It  is  most  usual  for  a contracted  state  to  exist  in  conjunc- 
tion with  morbid  adhesion,  because  the  probability  is,  that  the  uterus  will1 
have  made  some  efforts  to  expel  it,  and  not  being  able  to  protrude  it  from 
its  cavity,  it  will  have  closed  upon  it.  We  shall  also  sometimes  meet' 
with  it  partially  extruded  from  the  uterine  cavity,  and  a greater  or  less 
portion  lying  loose  in  the  vagina,  and  we  may  trace  it  passing  through 
the  os  uteri,  and  find  another  part  adherent  to  the  organ  within.f  This 
condition  can  hardly  happen,  indeed,  unless  the  attachment  had  been  ori- 
ginally much  lower  than  is  usual,  or  unless  the  placenta  be  oval  rather  ■ 
than  round  in  form ; but  when  it  does  occur,  it  may  be  the  cause  of  much  j 
embarrassment,  and,  if  not  understood,  of  great  danger.  So  long  as  any 
portion  remains  connected  by  morbid  organization  with  the  uterine  sur- 
face, so  long  any  attempts  to  remove  it  by  traction  at  the  cord,  or  even  by 
pulling  at  the  placenta  itself,  must  be  in  the  highest  degree  hazardous;  and 
for  this  reason  I have,  on  a former  occasion,  inculcated  the  caution  not  to 
attempt  its  removal  by  the  agency  of  the  funis,  until  not  only  the  insertion 
of  the  cord  can  be  easily  distinguished, — not  only  the  bulk  of  the  placenta 
can  be  clearly  felt,  but  its  general  body  can  be  completely  surrounded  by 
the  finger,  introduced  as  in  a common  examination.  The  management  of  s 

* See  Hamilton’s  Outline  1840,  p.  168;  my  father’s  Practical  Observations,  p.  75  ; and  Bar- 
low’s Essays,  p.  250. 

t See  my  father’s  Practical  Observations,  part  i.  p.  78 ; and  Ingleby  on  Uterine  Haemor- 
rhage, p.  200. 


RETAINED  PLACENTA. 


377 


the  case  I am  supposing  must  be  conducted  on  exactly  the  same  principles 
as  if  the  whole  organ  was  shut  up  within  the  uterine  cavity. 

We  may  suspect  that  morbid  adhesion  exists,  if  after  the  birth  of  the 
child  the  placenta  does  not  descend,  although  the  uterus  continues  mode- 
rately active ; and  if;  on  putting  the  funis  rather  on  the  stretch,  and  then 
letting  it  suddenly  go,  it  springs  up  with  a sort  of  jerk : but  we  can  oniy 
positively  detect  the  true  nature  of  the  case  when  the  hand  is  in  the  uterus 
for  the  purpose  of  taking  it  away. 

Treatment . — The  removal  is  to  be  conducted  on  exactly  the  same  prin- 
ciples as  I before  mentioned.  The  hand  is  to  be  carried  up  to  the  placenta  ; 
we  are  to  seek  for  an  edge  which  has  been  separated,  and  is  lying  loose; 
insinuate  the  fingers  cautiously  between  this  and  the  uterine  surface ; and 
by  gently  moving  the  hand  from  side  to  side  with  a sawing  kind  of 
motion, — keeping  the  palm  towards  the  placenta,  and  the  knuckles  next 
the  uterus, — we  continue  the  separation  until  we  find  that  we  have  encom- 
passed the  whole  of  the  organ,  and  that  it  drops  loose  into  our  hand : or 
if  the  adhesion  be  too  firm  to  give  way  to  this  mode  of  proceeding,  we 
may  often  succeed  in  removing  the  whole  by  cautiously  working,  or  pick- 
ing the  adherent  portions  off,  as  it  were,  with  each  finger  separately. 

Either  of  these  methods  is  ini  my  estimation  by  far  preferable  to  that  re- 
commended by  Hamilton*  and  Burnsf— expanding  the  fingers  over  the 
foetal  surface,  and  squeezing  the  edges  towards  the  centre  ; because,  if  the 
agglutination  be  firm,  we  are  very  likely  to  break  the  placenta,  and  leave 
filaments  still  adherent.  The  principal,  and  indeed  the  only  objection  to 
the  plan  I adopt,  is  the  chance  of  bruising,  scratching,  or  slightly  tearing 
the  uterine  membrane  with  the  ends  of  the  fingers,  the  nails,  or  the 
knuckles  i and  no  doubt,  if  the  nails  be  long,  pointed,  or  rough,  at  their 
extremities,  or  the  operation  be  performed  hurriedly  or  inconsiderately, 
such  accidents  are  very  likely  to  happen ; but  I take  it  for  granted  that  due 
caution  will  be  used,  and  I am  myself  not  aware  of  ever  having  inflicted 
injury  under  the  operation. 

The  hand  should  not  be  withdrawn  from  the  uterus  until  the  entire  sepa- 
ration is  effected,  and  we  must  be  most  particular  in  removing  every  par- 
ticle of  the  mass*  I know  that  to  get  it  all  away  is  sometimes  impracti- 
cable, owing  to  the  strength  of  the  adhesion  ; but  such  cases  are  fortunately 
rare.  I know,  also,  that  we  are  told  by  some  authorities  of  great  weight, 
that  should  the  placenta  break  uncfer  the  action  of  the  hand,  we  are  not 
to  use  much  effort  to  procure  it  all,  but  remove  what  we  oan,  and  leave 
the  remainder.^  I cannot  help  thinking  that  such  a doctrine  is  highly 

* Op.  cit.  p.  171 . f Op.  bit.  p.  363. 

t Blundell,  Obstet.,  p.  628  ; Burn’s  Princ.  of  Mid.,  p.  363  ; Hamilton,  Pract.  Qbs.,  pp.  171 
and  175  ; Davi's,  Obst.  Med.  parag.  1063. 

48 


378 


COMPLEX  LABOURS. 


dangerous,  by  impressing  the  student  with  the  belief  that  in  many  cases 
its  entire  separation  is  impossible , and  perhaps  by  lulling  him  into  a fatal 
carelessness.  It  would  be  my  wish,  on  the  contrary,  to  inculcate  the  idea 
that  the  whole  can  very  generally,  and  ought,  even  at  the  expense  of  some 
trouble,  to  be  removed ; and  that  we  should  never  feel  satisfied  that  we 
have  done  our  duty,  unless  wTe  have  used  our  best  endeavours  to  effect  its 
entire  abstraction.  The  recommendation  given  by  those  practitioners  who 
think  differently  with  myself,  is  founded  on  the  supposition  that  more  dan- 
ger would  accrue  by  our  attempts  at  separating  the  strongly-adherent  por- 
tions than  by  leaving  a part  of  it  behind.  From  some  practical  observation, 
however,  I am  persuaded  that  very  few  states  after  delivery  are  fraught 
with  such  extreme  peril  as  that  in  which  any  portion  of  the  placenta  re- 
mains adherent  to  the  uterine  surface;  and  I believe,  also,  both  that  the 
uterine  membrane  is  not  so  liable  to  serious  injury  as  has  been  supposed, 
and  that,  if  injured,  it  possesses  great  powers  of  reparation  within  itself : 
and  for  these  reasons  I consider  it  my  duty  strongly  to  enforce  the  prac- 
tice I have  just  ventured  to  advocate.  On  examining  the  placenta,  also, 
after  its  removal,  if  a large  proportion  be  wanting,  I think  it  better  to  in- 
troduce the  hand  a second  time  immediately,  under  the  employment  of  the 
utmost  tenderness,  for  the  purpose  of  taking  the  disrupted  piece  away, — 
than  to  leave  it  to  be  expelled,  to  putrefy,  to  become  perhaps  the  nucleus 
for  hydatid  formations,  or  to  the  chance  of  its  absorption, 

I have  recommended,  for  the  reasons  assigned  when  treating  of  trans- 
verse presentations,  that  the  left  hand  should  be  employed  in  the  operation 
under  consideration  : other  practitioners  of  experience  prefer  the  right  with 
Hamilton*  and  Merriman  ;f  and  others  again,  as  Ingleby,J  introduce  the 
right  if  the  placenta  be  attached  towards  the  back  part  of  the  organ,  and 
the  left  if  forward ; and  they  judge  of  the  situation  of  the  mass  by  the  di- 
rection  in  which  the  funis  runs  upwards  into  the  cavity.  I am  not  satis- 
fied that  it  is  always,  nor  indeed  generally,  possible  to  tell  whether  the 
placenta  be  connected  anteriorly  or  posteriorly,  by  tracing  the  funis  up  ; 
to  the  pelvic  brim ; and  under  every  diversity  of  attachment,  I am  myself 
in  the  habit  of  using  the  left. 

It  cannot  have  escaped  the  observation  of  the  reader,  that  the  difficulty 
in  removing  an  adherent  placenta  will  be  dependent  upon  two  causes; 
partly  the  contracted  state  of  the  uterus  in  resisting  the  introduction  of  the 
hand,  but  principally  the  degree  of  its  adhesion,  both  in  extent  and  inten- 
sity ; so  that  we  have  a combination  of  difficulties,  only  to  be  overcome.Jw\ 
the  most  judicious  management,  and  not  to  be  undertaken  except  by  orifft 


* P.  171. 


t Synopsi?,  p.  147. 


t On  Uterine  Haemorrhage,  p.  185, 


RETAINED  PLACENTA. 


379 


who  has  acquired  an  intimate  acquaintance  with  the  structure  of  the 
parts. 

Although,  when  the  haemorrhage  is  copious,  the  manual  removal  of  the 
placenta  is  the  only  means  to  which  we  can  trust  for  the  closure  of  the 
uterine  cavity,  and  the  suppression  of  the  discharge,  still,  if  the  patient  be 
lying  under  a state  of  syncope,  it  would  be  improper  to  empty  the  uterus 
until  the  system  has  somewhat  rallied,  lest  the  organ  be  left  in  a flaccid 
condition,  and  on  the  restoration  of  the  heart’s  action  a fresh  and  more 
violent  eruption  should  ensue ; for  it  cannot  be  too  strongly  or  too  fre- 
quently impressed  on  the  mind  of  the  junior  practitioner,  that  the  removal 
of  the  placenta  is  not  our  only  object,  but  that  a chief  part  of  our  attention 
should  be  directed  to  producing  a firm  and  permanent  state  of  contraction 
in  the  uterus  itself.  Gooch,  indeed,  used  to  declare,  “ he  could  positively 
assert  from  experience,  that  the  organ  would  contract  even  during  syn- 
cope,” but  he  acknowledged  its  action  under  such  circumstances  was 
feeble.*  I do  not  mean  to  deny  the  possibility  of  contraction  occurring 
under  a temporary  suspension  of  the  vital  functions ; but  I greatly  fear 
that,  in  the  generality  of  such  cases,  we  should  be  disappointed  in  our  ex- 
pectation ; and  I am  also  convinced,  that  the  safest  plan  is  that  I have  just 
advised.  The  exhibition  of  stimuli,  then  may  become  necessary  to  rouse 
the  torpid  energies  before  the  operation  is  proceeded  in. 

A morbid  union  appears  occasionally,  though  very  seldom,  to  take  place 
between  the  foetal  membranes  and  the  decidua,  or  the  uterine  surface,  at 
a greater  or  less  distance  from  the  point  of  placental  attachment;  and  if 
such  an  adhesion  be  to  any  considerable  extent,  it  may  prevent  the  occlu- 
sion of  the  placenta  from  the  uterine  cavity,  and  consequently  be  the  cause 
of  a retention  of  the  mass.  We  should  not,  cl  priori , suppose  that  agglu- 
tination, by  the  deposition  of  coagulable  lymph,  would  occur  between  the 
uterine  membrane  and  the  chorion,  from  the  great  dissimilarity  of  their 
tissues ; but  I am  persuaded  I have  known  not  a few  instances  in  which 
such  an  adhesion  impeded  the  descent  of  the  placenta  into  the  vagina. 
The  case  must  be  treated,  nearly  in  every  respect,  on  the  principles  already 
laid  down,  and  the  separation  is  generally  not  difficult  to  be  effected. 

It  is  a remark  made  by  most  practical  men,f  that  some  women  seem 
constitutionally  subject  to  an  adhesion  of  the  placenta ; so  that  this  cause 
of  danger  exists  in  almost  every  successive  pregnancy;  and  I have  myself 
known  several  examples  of  this  unfortunate  peculiarity.  It  becomes,  then, 
appoint  of  some  importance  to  ascertain  whether,  by  any  means  applied 
^during  gestation,  the  danger  might  not  be  obviated.  Quietude,  rest,  regu- 
lar attention  to  the  action  of  the  bowels,  an  unstimulating  diet,  and  the 


Compendium  by  Skinner,  p.  175. 


f Hamilton,  Tract.  Obs.  p.  169. 


occasional  abstraction  of  blood — particularly  if  the  circulation  be  hurried, 
or  a fixed  pain  show  itself  in  the  uterine  region— seem  to  offer  the  best 
chance  of  success.  With  regard  to  bleeding  under  pregnancy,  I am  cer- 
tainly averse  from  it,  unless  there  exist  some  grave  occasion;  and  as  a 
principle,  do  not  coincide  with  those  practitioners  who  have  frequent  re- 
couise  to  the  lancet  to  prevent  flooding  in  labour,  where  the  uterus  is  con- 
stitutionally disposed  to  remain  flaccid  after  the  birth  of  the  child : because 
in  such  patients  the  powers  of  life  are  generally  weak,  the  habit  is  relaxed, 
and  the  system  not  in  a condition  to  bear  up  against  the  effects  of  deple-j 
tion.  If  blood  be  formed  rapidly,  indeed— as  is  sometimes  the  case  under 
pregnancy — the  lancet  may  be  advantageously  employed  for  the  object] 
in  question:  and  if  there  be  undue  determination  to  any  particular  organ, 
bleeding  is  even  more  neeessary  than  in  the  unimpregnated  state;  for  it  is 
a common  observation,  both  that  inflammatory  disease  runs  on  to  its  ter- 
mination more  speedily  during  gestation,  and  that  the  loss  of  more  blood 
is  required  for  its  subdual,  than  in  the  ordinary  condition  of  the  system; 
and  I think  I have  on  some  occasions  seen  the  advantage  of  the  abstrac- 
tion of  blood  in  preventing  placental  adhesion. 

Disrupted  Placenta, — When  a portion  of  the  placenta  is  left  in  utero, 
the  patient  is  generally  harassed  with  violent  after-pains  returning  at  longer 
<pr  shorter  intervals,  preventing  sleep,  and  causing  excessive  irritability. 
Py  degrees  the  pain  becomes  more  continual,  and  at  last  almost  incessant,] 
^nd  is  much  increased  on  pressure  being  applied  over  the  hypogastric 
Region,  and  on  putting  the  infant  to  the  breast.  On  the  first  violent  erup- 
tion ceasing,  the  uterine  discharge  is  usually  moderate,  with  the  expulsion 
of  occasional  coagula.  In  the  course  of  two  or  three  days  it  assumes  a 
character  far  from  natural;  it  becomes  sanious,  of  a dark  and  dirty  brown 
Colour,  putrescent,  and  necessarily  highly  offensive  to  the  smell;  and, 
together  with  the  exuding  fluid,  small  shreds  of  putrid  placenta  will  some- 
times pass.  Shortly  the  system  in  general  sympathizes  with  the  unhealthy 
state  of  the  uterine  organ ; febrile  symptoms,  violent  in  degree,  supervene, 
ushered  in  by  one  or  more  rigours ; the  pulse  soon  becomes  rapid,  and  is 
generally  small ; there  is  heat  and  cfi'yness  of  skin,  more  particularly  on 
the  abdomen;  immoderate  thirst;  great  anxiety  both  of  countenance  arifP 
mind;  restlessness,  almost  amounting  to  jactitation;  frequent  sighings; 
occasional  vomiting,  or  a distressing  sensation  of  choking,  especially 
attempting  to  take  fluids,  and  perhaps  also  on  pressure  being  applied  to^ 
the  uterine  region ; uninterrupted  wakefulness ; a diminution  in  the  secre- 
tion of  milk  ; the  tongue  white,  loaded,  and  slimy,  or  red,  dry*  and  shining? 
and  there  is  more  or  less  headach,  with  wandering  of  the  mind.  Some- 
times the  pain  in  the  head  is  of  a pulsatory  character,  and  constant;  at 
others,  of  a sharp,  darting  kind,  and  intermitting.  Another  very  common? 


DISRUPTED  PLACENTA. 


381 


indeed  almost  universal  symptom,  is  erratic  pains  in  different  parts  of  the 
body,  most  usually  darting  from  hip  to  hip,  or  situated  in  the  region  of 
the  diaphragm,  much  impeding  respiration,  and  varying  in  intensity  as  in 
situation.  The  bowels  at  first  are  more  torpid  than  ordinary,  but  after  a 
time  they  become  much  relaxed,  and  there  is  difficulty  in  checking  their 
action.  As  the  case  proceeds,  the  dangerous  symptoms  progressively 
increase ; the  strength  hourly  diminishes ; the  belly  swells,  and  becomes 
tense;  low  delirium  supervenes;  the  tongue  acquires  the  typhoid  character; 
vomiting  of  dark  coffee-ground-like  matter  occurs;  the  extremities  become 
cold ; the  foecal  evacuations  and  urine  are  voided  involuntarily ; subsultus 
tendinum  comes  on ; and  the  patient  sinks  within  ten  or  twelve  days  after 
delivery. 

It  is  not  always,  however,  that  the  disease  runs  this  fatal  course.  Some- 
times the  putrid  mass  is  thrown  off  from  the  uterus,  and  relief  almost  in- 
stantaneously follows : at  others,  the  symptoms  never  assume  such  vio- 
lence of  form ; and  on  the  third  or  fourth  day  from  delivery,  a purulent 
discharge,  almost  devoid  of  any  unpleasant  smell,  flows  from  the  vagina, 
in  which  filaments  of  the  placenta  are  discernible,  and  which  often  lasts 
for  two  or  three  weeks.  I suspect  this  discharge  to  be  a secretion  from 
the  inner  surface  of  the  uterus,  consequent  on  inflammation,  and  to  be  a 
means  adopted  by  Nature  to  get  rid  of  the  offending  body,  and  always 
hail  its  appearance  as  one  of  the  best  signs  we  can  observe.  I seldom 
saw  it  afforded  in  such  quantity  as  materially  to  depress  the  vital  powers, 
and  still  less  frequently  have  I known  death  ensue  where  it  had  been  freely 
formed.*  At  other  times,  again,  but  very  rarely,  the  remaining  portion  of 
placenta  becomes  the  nucleus  for  hydatidinous  formations;  and  more 
rarely  still,  it  may  be  actually  absorbed,  or  retaining  its  connexion  with 
the  womb,  may  possibly  become  organized. 

Treatment. — When  the  haemorrhage  has  ceased,  which  must  be  met 
by  such  means  as  have  more  than  once  been  insisted  on,  our  treatment 
must  entirely  depend  on  the  violence  of  the  symptoms  present.  The 
bowels  must  be  moderately  opened  in  the  first  instance,  and  their  action 
restrained  afterwards,  if  inordinate ; the  irritability  of  stomach  may  per- 
haps be  allayed  by  effervescent  draughts ; and  sedative  medicines,  either 
S^Dpium  itself,  or  those  of  a milder  kind,  will  generally  be  found  useful. 
'There  exists  a little  difference  of  opinion  among  practical  men  as  to  the 
propriety  of  removing  the  after-pains  by  opiate  remedies.  My  fatherf 
and  BlundellJ  think  it  better  not  to  interfere  with  the  uterine  contractions, 

* “ In  rare  and  mild  cases  [of  disrupted  placenta]  a puriform  discharge  has  escaped  from 
the  vagina.”  Ingleby,  p.  212. 

t Pract.  Obs.  Part  I.  p.  167. 


4 Obs.  by  Castle,  p.  612. 


382 


COMPLEX  LABOURS. 


because  through  their  agency  it  is  probable  the  irritating  mass  may  be 
expelled.  On  the  contrary,  others,  as  Ingleby,*  regard  opium  as  called 
for.  For  myself,  considering  the  distress  these  pains  produce,  I think  it 
better  to  alleviate  them,  more  especially  as  they  frequently  fail  in  pro- 
ducing the  good  anticipated,  and,  by  their  severity,  occasion  excessive 
irritability.  Bleeding  from  the  arm  will  seldom  be  borne  with  impunity 
but  more  relief  will  be  obtained  by  the  application  of  leeches  to  the  ute- 
rine region.  I have  occasionally  found  benefit  from  counter-irritants  ap- 
plied to  the  side  of  the  chest,  or  that  part  where  the  sympathetic  pain  was 
most  acute ; but  not  so  frequently  as  I could  have  desired.  As  these 
pains,  indeed,  are  usually  erratic,  and  dependent  (as  I presume)  on  the 
state  of  the  uterine  membrane,  it  is  reasonable  to  suppose  that  more  advan- 
tage will  be  derived  from  local  applications  to  the  uterus  or  its  neighbour- 
hood, than  to  the  immediate  seat  of  painful  sensation.  Under  this  idea  ] 
have  generally  directed  my  attention  to  the  uterus,  and  my  means  to  over- 
coming the  disease  existing  in  its  structure : next  to  leeches,  then,  I have 
thought  relief  has  been  obtained  from  external  fomentations,  and  particu- 
larly injections  of  warm  water  into  the  vagina  or  cavity  of  the  uterus 
itself.  If  the  os  uteri  be  not  morbidly  tender,  the  nozzle  of  a properly- 
contrived  syringe  may  be  passed  just  within  the  orifice ; but  if  this  attempt 
should  give  much  pain,  the  vagina  may  be  washed  out  every  two  or  three 
hours.  The  application  soothes  the  parts,  by  acting  as  an  internal  fomen- 
tation, cleanses  them  of  any  putrid  fluid  which  may  be  lodging  within  them 
and  may  perhaps  even  tend  to  separate  the  adherent  portions  of  placenta, 
and  bring  them  away.  A weak  solution  of  the  chloride  of  lime  or  soda 
may  be  substituted  for  the  plain  water,  sometimes  with  advantage.  Wher 
the  symptoms  of  excitement  have  merged  into  those  of  depressed  powers, 
wine,  aether,  ammonia,  bark,  and  aromatics,  may  be  used;  but  their  effi- 
cacy in  restoring  the  system  to  a healthy  state  is,  at  the  best,  inconsi-, 
derable. 

Accidents  likely  to  happen  on  attempts  to  remove  the  placenta  from 
the  uterus,  by  pulling  at  the  funis. — The  cautions  to  which  the  student’s 
mind  has  been  directed,  regarding  the  necessity  of  waiting  until  the  pla- 
centa is  wholly  lodged  in  the  vagina,  before  any  attempt  is  made  to  with- 
draw it  by  the  funis,  are  not  without  their  object : for  if  the  mass  be  adhe- 
rent, we  shall  either  separate  it  farther  from  its  attachment;  or  we  shall 
break  it,  leaving  a part  in  utero ; or  we  shall  rupture  the  funis,  or  cause  if 
and  the  membranes  to  slip  away  from  the  bed  of  the  placenta ; or,  lastly, 
we  shall  invert  the  uterus  itself.  Of  these  accidents,  breaking  the  funis  is 


* On  Uter.  Haem,  p.221. 


INVERSION  OF  THE  UTERUS. 


383 


the  least,  inverting  the  uterus  the  most  dangerous,  in  its  consequences.  If 
we  break  the  funis,  we  certainly  lose  it  as  a guide  to  the  placenta ; but 
this  is  not  of  much  importance.  We  can  pass  the  hand  into  the  uterus, 
and  remove  the  placenta, — should  such  practice  be  necessary, — when  the 
funis  is  broken  off,  almost  as  well  as  when  it  is  entire,  and  its  value  as  a 
guide  is  on  the  whole  but  trifling.  If,  by  our  improper  interference,  we  sepa- 
rate a larger  portion  of  the  placenta,  we  shall  bring  on  an  increase  of 
haemorrhage,  which  will  probably  require  the  instant  withdrawal  of  the 
mass.  If  we  extract  only  a part,  leaving  a large  portion  behind,  we  shall 
also  require  to  introduce  the  hand  for  the  purpose  of  removing  the  re- 
mainder. But  it  is  possible  that  we  may  even  invert  the  uterus : for  if  the 
placenta  be  adherent  to  the  fundus  of  the  organ, — if  the  adhesion  be  strong, 
— if  the  funis  does  not  give  way  to  the  force  applied  to  it, — and  if  the 
uterus  be  flaccid,  and  have  not  contracted  round  the  mass, — the  fundus 
will  descend,  pass  through  the  os  uteri  into  the  vagina,  and  the  viscus  will 
be  turned  inside  outwards,  as  a pocket  might  be.* 

Whenever  this  serious  accident  has  happened  (which  may  generally  be 

* The  most  horrifying  case  of  mismanagement,  perhaps,  that  ever  occurred  either  in 
medicine  or  surgery,  arose  from  an  adhesion  of  the  placenta,  and  is  put  on  record  by 
Dr.  Boys,  formerly  physician. accoucheur  to  the  Westminster  General  Dispensary.  He 
was  present  at  the  dissection  of  the  body,  together  with  Mr.  Brookes,  Drs.  Hooper,  Fo- 
thergill,  and  several  other  gentlemen.  They  found  wanting — the  uterus,  right  ovarium 
and  tube,  part  of  the  vagina,  and  part  of  the  left  fallopian  tube ; the  greatest  part  of  the 
rectum,  caecum,  appendix  vermiformis,  the  ascending  portion  of  the  colon,  the  right  side 
of  the  transverse  arch,  all  the  ilium  and  inferior  part  of  the  jejunum, — altogether  many  feet 
of  the  small  intestines, — with  part  of  the  mesentery,  and  the  greater  part  of  the  omentum 
majus,  which  had  been  torn  away  from  the  right  side  of  the  large  curvature  of  the  stomach. 
The  remaining  portion  of  the  transverse  arch  of  the  colon,  and  much  of  the  jejunum,  were 
torn  from  their  attachments.  The  labour  occurred  on  September  18th,  1807,  and  was  com- 
plicated with  an  adherent  placenta.  The  attendant  broke  the  placenta  by  pulling  at  the  funis. 
This  produced  haemorrhage,  and  he  left  the  patient.  In  about  fifty  hours,  no  attempt  having 
been  made  to  relieve  her,  the  nurse  found  something  hanging  out  of  the  external  parts ; and  on 
his  being  apprized  of  it,  he  said  it  must  be  taken  away,  and  placed  her  on  her  left  side  for 
that  purpose.  He  made  use  of  considerable  exertion,  and  caused  great  pain.  He  then  or- 
dered a pair  of  scissors  to  be  brought,  saying  there  was  a false  conception,  which  must  be 
removed : while  using  them  the  patient  fainted,  and  died  immediately.  The  parts  removed 
by  this  brutal  operator  were  preserved,  and  proved  to  be  those  I have  just  mentioned.  We 
could  scarcely  suppose  that  such  ignorance  and  barbarity  could  exist,  as  exemplied  in  the 
conduct  of  this  case.  But,  independently  of  the  precise  account  drawn  up  by  Dr.  Boys,  (a 
letter  on  the  Practice  of  Midwifery,  occasioned  by,  and  including  an  account  of  the  late  unfor- 
tunate case,  by  John  Boys,  M.D.,  &c.,  1808,)  we  have  father’s  testimony  in  corroboration  ; for 
he  saw  the  parts  in  Mr.  Brookes’s  dissecting-room.  Ths  man  was  tried  at  the  Old  Baily  for 
murder,  and  was  acquitted. 

Ruysch  (Pract.  Obs.  in  Surgery  and  Midwifery,  trans.  1751,  p.  33)  says  he  has  met  with 
two  instances  of  inverted  uterus  within  one  week.  After  this  declaration,  we  cannot  wonder 
that  Ruysch,  placed  in  so  responsible  an  office  at  Amsterdam,  should  have  written  so  strongly 
against  removing  the  placenta  artificially  in  any  case. 


384 


COMPLEX  LABOURS. 


looked  upon  as  the  consequence  of  improper  treatment,)  it  may  be  known 
by  the  placenta  still  remaining  adherent,  though  perhaps  external  to  the 
vulva ; by  the  sudden  appearance  of  the  sensitive  tumour  which  occupies 
the  vagina ; and  by  the  womb  not  being  discernible  above  the  pubes  by 
the  hand  applied  over  the  abdominal  parietes.  It  must  immediately  be 
restored  to  its  former  state ; for  the  lapse  of  every  minute  will  be  of  con- 
sequence* since  the  longer  we  delay,  the  more  difficulty  shall  we  expe- 
rience in  its  reduction.  For  this  purpose,  the  hand  being  half-shut,  the 
back  of  the  fingers  are  to  be  pressed  firmly  against  the  most  depending 
point  of  the  tumour;  when  the  part  will  yield,  the  fundus  will  pass  up  with 
a sort  of  jerk,  the  organ  will  be  restored  to  its  natural  situation,  and  the 
hand  will  occupy  the  cavity.  The  placenta  may  now  be  removed,  as 
before  recommended ; and,  on  the  hand  being  withdrawn,  the  greatest  possi- 
ble care  must  be  taken  that  the  inversion — of  which  there  is  some  proba- 
bility— does  not  occur  again.  Unless  this  restoration  be  effected  within  a 
short  period  of  the  time  when  the  accident  took  place,  I should  presume 
either  that  the  uterus  could  not  be  reduced  at  all,  or  that  the  haemorrhage 
must  be  excessive. 

Marty  practitioners*  recommend  that  the  placenta  should  be  separated 
from  its  attachment  before  any  attempt  is  made  to  replace  the  uterus.  I 
should  myself  much  prefer  acting  as  just  advised,  because,  should  the  de- 
tachment be  effected  while  the  organ  remains  in  its  inverted  state,  either 
the  woman  must  lose  a very  great  quantity  of  blood  from  the  patulous 
orifices  of  the  exposed  vessels ; or,  if  such  a degree  of  contraction  took 
place  as  to  stop  the  haemorrhage,  that  very  shrinking  of  the  uterine  pa- 
rietes would  preclude  the  possibility  of  restoring  it  to  its  natural  state.f 

* Puzos  traitedes  Accouch.  4to.  1759,  p.  250;  Davis,  p.  1088;  Velpeau,  p.  521,  &c. ; Burns, 
p.  501.  and  Dewees,  parag.  1309,  recommend  the  uterus  to  be  restored  before  removing  the 
placenta.  Denman,  chap.  15,  sect.  12,  and  Blundell,  p.  693,  that  if  the  placenta  be  detached 
to  a considerable  extent,  it  should  be  separated  first;  if  it  be  entirely  adherent,  it  should  be  re- 
turned with  the  uterus,  and  removed  afterwards. 

•f-  Three  cases  of  inverted  uterus  have  come  under  my  observation.  In  one  I was  requested 
to  be  present  at  the  inspection  of  the  body  of  a woman  who  had  died  from  flooding  soon  after 
delivery ; we  found  the  uterus  completely  inverted,  and  lying  in  the  vagina.  The  attendant 
had  separated  the  placenta  after  the  accident,  and  had  contented  himself  with  hiding  the  organ 
from  sight  within  the  external  parts.  The  second  was  some  weeks  after  delivery.  The  uterus 
was  contracted  to  its  small  unimpregnated  size, — almost  as  well,  indeed,  as  though  it  was  in 
situ;  but  the  patient  was  draining  to  death  with  a copious  foetid  discharge.  The  last  patient  I 
saw  about  twelve  hours  after  the  accident  had  happened,  on  July  20th,  1839  : she  had  lost  a 
large  quantity  of  blood,  and  was  much  depressed.  I made  an  attempt  to  revert  the  uterus 
without,  however,  much  hope  of  succeeding.  She  suffered  from  irregular  haemorrhage  to  a 
most  copious  extent,  with  occasional  severe  pain  in  the  lumbar  region,  so  as  to  reduce  her  to 
a state  of  extreme  danger,  and  confine  her  entirely  to  the  house  till  the  middle  of  October, 
when  she  was  able  to  go  out  two  or  three  times;  she  then  had  no  haemorrhage,  but  a copious 
glairy  leucorrhceal  discharge,  and  violent  bearing  down  pains.  Towards  the  end  of  December 


HEMORRHAGE  AFTER  REMOVAL  OF  PLACENTA.  385 


Errors  liable  to  be  committed. — The  errors,  then,  that  the  inexperienced 
practitioner  is  liable  to  commit  in  a case  of  adherent  placenta,  are  many. 
He  may  pull  too  violently  at  the  cord,  and  cause  rupture  of  the  placenta, 
rupture  of  the  cord,  or  inversion  of  the  uterus.  He  may  be  too  fond  of 
removing  the  placenta  by  the  introduction  of  the  hand  soon  after  the  birth 
of  the  child.  He  may  also — but  of  this  there  is  less  danger — delay  ex- 
tracting it  until  it  be  too  late,  when  the  patient  having  fainted  frequently, 
lies  gasping  and  tossing  about,  and  is  cold  in  the  limbs,  and  a cold  sweat 
breaks  out  on  the  upper  part  of  her  person.  He  may  use  too  much  force 
in  introducing  the  hand,  and  bruise  the  vagina  or  uterus,  and  too  little 
care  in  separating  the  placenta,  leaving  a greater  or  less  portion  behind. 
He  may  suppose,  because  he  can  feel  part  of  the  placenta,  that  therefore 
it  must  be  entirely  in  the  vagina ; and  he  may  endeavour  to  remove  it  by 
pulling  at  the  mass ; he  may  therefore  break  it,  withdraw  half,  and  allow 
the  remainder  to  lodge  in  the  uterus,  and  by  its  putrefaction  to  become 
the  occasion  of  that  train  of  distressing  and  highly  dangerous  symptoms 
which  I have  just  enumerated;  or,  lastly,  he  may  not  pay  sufficient  atten- 
tion to  the  necessity  of  procuring  a thoroughly  contracted  uterus ; he  may 
take  away  the  placenta,  and  leave  that  organ  in  a flaccid  state,  the  cause 
of  a persistence  of  the  bleeding. 

Hemorrhage  subsequent  to  the  removal  of  the  placenta. — Even  after 
the  placenta  has  been  expelled  naturally, — or  more  frequently  after  it  has 


she  was  again  attacked  with  flooding  to  a frightful  degree,  and  on  its  moderating  she  was  re- 
moved a short  distance  from  London.  I did  not  sec  her  again  till  the  summer,  when  1 found 
her  health  generally  rather  improved,  although  the  hemorrhage  and  leucorrhaea  had  continued 
almost  incessantly  throughout  the  spring.  On  June  5th,  with  the  assistance  of  Mr.  Hamilton, 
of  the  London  Hospital,  and  Mr.  Farrants,  the  attending  apothecary,  I placed  a ligature  round 
the  base  of  the  tumour, — then  about  the  size  of  a small  nonpareil  apple, — intending  to  allow  it 
to  remain  until  the  uterus  sloughed  away.  The  application  gave  but  little  pain:  on  the  next 
day,  however,  there  was  every  symptom  of  violent  peritoneal  inflammation,  ushered  in  by  a 
rigour  that  came  on  three  or  four  hours  after  the  operation ; there  had  not  been  the  least  dis- 
charge  of  blood  since  the  application  of  the  ligature.  The  distress  was  so  great,  and  the  dan- 
ger appeared  so  urgent,  that  it  was  thought  right  to  remove  the  ligature,  which  was  done 
twenty-four  hours  after  it  was  tied.  The  pain  and  other  inflammatory  symptoms  gradually 
subsided;  in  a few  days  she  was  able  to  leave  her  room;  she  menstruated  on  July  13th,  and 
has  continued  to  do  so  regularly  every  month  since,  without  pain,  or  the  expulsion  of  coagula; 
the  discharge  lasts  from  two  to  three  days,  and  is  moderate  in  quantity  ; she  has  no  leucorrhaea; 
she  has  regained  her  flesh,  colour,  and  appetite ; can  take  a long  walk  ; has  no  bearing  down, 
nor  any  difficulty  in  passing  water;  she  can  move  and  sit  without  the  least  inconvenience;  her 
bowels  are  regular,  and  she  says  she  enjoys  now  better  health  than  she  has  had  for  some 
years.  Nothing  solid  has  passed  from  the  vagina  since  the  operation.  It  will  be  for  the  con- 
sideration of  the  profession,  whether  this  mode  of  treating  such  a case  may  be  resorted  to  on 
other  similar  occasions,  without  incurring  the  risks  necessarily  attendant  on  allowing  the  ute- 
rus  to  slough  away. 

49 


386 


COMPLEX  LABOURS, 


been  extracted  by  the  hand,  in  consequence  of  atony  of  the  uterine  fibres, 
— (notwithstanding  that  the  labour  is  said  to  be  terminated  so  far  as  the 
different  stages  are  concerned) — the  woman  is  liable  to  a continuance  of 
the  haemorrhage,  or  to  a fresh  accession,  owing  to  the  want  of  due  con- 
traction in  the  uterine  parietes. 

Causes . — We  shall  generally  find  that  this  description  of  case  occurs  to 
women  of  a relaxed  habit,  and  weak  muscular  fibre — to  those  who  have 
borne  a great  many  children,  or  after  a lingering  or  instrumental  labour; 
or  in  cases  where  the  child’s  body  has  been  hurriedly  extracted  after  the 
head  is  born.  Exactly  the  same  causes,  indeed,  will  produce  this  state, 
as  vrould  occasion  that  inertia  of  which  the  retention  of  the  placenta  itself 
is  the  consequence. 

Frequently,  under  these  circumstances,  the  blood  escapes  externally ; at 
other  times  it  is  retained  in  the  uterus.  A coagulum  forms  at  the  os  uteri, 
and  the  effect  of  this  plug  is  obvious ; the  blood  is  poured  out  from  the 
open  vessels  into  the  uterine  cavity,  is  prevented  flowing  forth,  but  con- 
tinues accumulating  within,  sometimes  to  an  amazing  extent.  The  danger, 
as  before  remarked,  is  even  greater  than  when  the  haemorrhage  is  exter- 
nal, both  because  the  case  may  be  overlooked,  and  because  the  more  the 
uterus  is  distended, — the  more  blood  the  cavity  contains, — the  larger  do 
the  vessels  become,  dilating  in  their  calibre  in  proportion  as  the  womb  in- 
creases. The  organ  has  been  known  to  acquire  a size,  after  the  birth  of 
the  child  and  extraction  of  the  placenta,  almost  as  large  as  it  was  pre- 
viously to  the  commencement  of  labour,  so  that  its  fundus  rises  above  the 
umbilicus,  and  its  cavity  contains  many  pints  of  blood.  Notwithstanding 
this  internal  accumulation,  scarcely  a stain,  perhaps,  appears  externally. 

Sometimes  the  uterus  contracts  tolerably  well  immediately  after  deli- 
very, and  then  again  relaxes,  contractions  alternating  with  relaxations, 
until  a very  considerable  quantity  of  blood  having  been  lost,  the  patient 
sinks.  It  is  on  this  account  that  I have  more  than  once  recommended 
that  the  uterine  tumour  should  be  examined,  by  the  hand  applied  over  the 
abdomen,  three  or  four  times  within  tne  first  hour  after  delivery;  and  that 
the  patient  should  not  be  left  until  the  attendant  is  satisfied  of  the  perfect 
and  continued  contraction  of  the  organ. 

Still  another  sort  of  case  occurs,  which  we  should  scarcely  expect,— a 
dangerous  degree  of  haemorrhage  notwithstanding  the  uterus  is  acting 
powerfully,  as  evinced  by  violent  after-pains.  We  lay  it  down  as  a princi- 
ple,^true  enough  in  general, — that  the  more  strongly  the  womb  contracts 
after  delivery,  the  less  danger  is  there  of  bleeding;  but  this  proposition 
only  applies  to  cases  where  the  cavity  is  empty.  If  it  contain  a portion  of 
the  placenta,  or  any  other  substance,  its  fibres  may  act  preternaturally 
strongly,  to  expel  the  offending  body ; and  yet,  as  the  cavity  is  not  perfectly 


hemorrhage  after  removal  of  placen  t a.  387 

closed,  haemorrhage  may  go  on  from  the  uncontracted  vessels.  Now,  oc- 
casionally the  coagula  which  connect  within  the  womb  acquire  such  a de- 
gree of  tenacity,  that  they  adhere  to  the  internal  membrane  almost  as 
firmly  as  the  placenta  itself  under  morbid  agglutination  ; and  there  is  nearly 
the  same  improbability  of  their  natural  expulsion.  Under  such  circum- 
stances, the  manual  removal  of  the  fibrinous  mass,  provided  it  can  be  ac- 
complished without  injury,  offers  the  best  chance  of  safety.* 

Of  all  these  three  states,  that  in  which  the  uterus  enlarges  rapidly,  fills 
with  blood,  and  shows  no  disposition  to  contract,  is  by  far  the  most  dan- 
gerous. 

Symptoms. — We  know  that  haemorrhage  is  going  on,  by  the  common 
symptoms  which  indicate  the  loss  of  blood.  The  colour  vanishes  from 
the  cheeks  and  lips;  the  pulse  flags;  fainting  occurs;  the  breathing  be- 
comes laborious,  and  drawn  with  sighs;  the  extremities  lose  their  warmth  ; 
jactitation  ensues,  and  perhaps  vomiting.  Vomiting,  indeed,  is  not  a 
universal  symptom  of  loss  of  blood,  and  seldom  comes  on  until  the  system 
is  much  depressed.  Under  great  exhaustion,  I consider  it  a good  sign, 
rather  than  a bad  one ; because  it  shows  that  the  nervous  system  is  not 
deadened,  but  that  impressions  are  still  kept  up  between  parts  remote  from 
each  other,  by  means  of  sympathy : and  I think,  also,  that  the  very  effort 
of  vomiting  tends  sometimes  to  induce  contraction  in  the  uterus,  and  may 
thus  be  the  means  of  preservation. 

We  know  too  that  the  woman  is  flooding, — if  it  be  external, — by  an 
examination  of  the  linen  : sometimes  we  find  a quantity  of  coagula  expelled 
upon  the  napkins ; at  others,  that  part  of  the  bed  in  which  the  woman  lies 
is  soaked  with  blood,  and  no  misapprehension  can  arise  as  to  the  cause  of 
the  diminished  vital  energy.  But  the  haemorrhage  may  be  internal  and 
concealed  ; still  our  means  of  diagnosis  is  easy  and  certain : the  simple  ap- 
plication of  the  hand  over  the  uterine  tumour  will  be  sufficient  to  assure 
us  of  its  state ; and  by  the  sensation  it  conveys,  we  judge  whether  blood 
is  pent  up  within  its  cavity.  If  we  find  the  organ  large,  soft, and  flaccid; 
if  it  yield  to  the  hand,  and  become  harder  when  pressure  is  made  upon  it, 
and  if  then  blood  passes  out  of  the  vagina  with  a gurgling  noise,  we  can 
be  at  no  loss  to  declare  the  case  one  of  concealed  hasmorrhage.  But,  on 

,>£fthe  contrary,  if  the  patient  continue  fainting,  while  there  is  no  external 
flow — if  we  find  the  uterus  as  small  as  a foetal  head,  and  hard,  and  observe 

« - 

•V’  " * It  has  happened  to  me  to  meet  with  many  cases  of  this  kind,  in  which,  although  the  uterus 
was  small  and  tolerably  firm,  a draining  of  blood  to  an  alarming  extent  was  going  on,  while  the 
patient  was  harassed  with  almost  insufferable  after-pains.  On  the  introduction  of  the  hand 
more  or  less  entirely  within  the  uterus,  and  the  removal  of  the  clots,  not  only  has  the  discharge 
ceased,  but  the  painful  contractions  have  also  in  a great  measure  disappeared ; and  almost  in- 
stantaneous security,  as  well  as  ease,  has  been  afforded. 


388 


COMPLEX  LABOURS. 


no  relaxation  in  its  structure — we  must  seek  some  other  cause  for  the 
symptoms  of  depression,  besides  loss  of  blood : — the  syncope  is  independent 
of  haemorrhage  from  the  womb. 

Treatment. — Under  haemorrhages  after  the  expulsion  of  the  placenta, 
our  indication  is  to  evacuate  the  uterus  so  as  to  ensure  the  closure  of  its 
cavity ; and,  if  necessary,  to  rouse  the  flagging  powers  by  the  judicious 
use  of  stimuli.  Both  outward  applications,  internal  remedies,  and  manual 
operations,  will  assist  us  in  the  accomplishment  of  our  purpose.  Pressure, 
and  the  application  of  cold,  will  often  of  themselves  prove  sufficient  to 
restrain  the  flow,  and  they  may  be  used  in  combination. 

Called,  then,  to  a case  of  this  description,  the  first  means  to  be  employed 
is  the  grasping  pressure  of  the  hand  to  the  uterine  tumour  itself.  It  is  not 
enough  merely  to  lay  the  open  palm  upon  the  abdomen,  and  press  steadily 
and  flatly ; but  a squeezing  or  kneading  action  should  be  used,  by  which 
the  organ  is  prevented  filling  and  becoming  distended  with  blood,  and  its 
fibres  also  are  stimulated,  to  contract.  It  is  not  unlikely  that  the  patient 
may  complain  of  the  pain  we  are  putting  her  to ; she  may  be  desirous  that 
our  hand  should  be  removed.  If  the  pain  she  experiences,  however,  be 
that  of  contraction,  her  entreaties  must  be  disregarded  ; because  upon  con- 
traction alone  her  ultimate  safety  will  depend.  At  other  times  she  will 
not  allow  us  to  leave  her  for  a single  minute ; she  feels  so  much  comfort 
from  the  pressure  of  the  hand  and  from  the  support  which  the  abdominal 
contents  receive,  and  she  experiences  such  a sensation  of  sinking  when 
that  pressure  is  removed,  that  she  feels  convinced  she  will  faint  if  it  be 
omitted.  While  haemorrhage  is  going  on  with  any  activity,  I place  no 
reliance  on  a bandage,  however  tight  it  may  be  drawn,  or  with  whatever 
local  compresses  its  action  may  be  aided.  I cannot  think  any  folds  of 
linen  applied  over  the  uterine  region,  can  secure  contraction  in  a manner 
at  all  to  be  compared  to  the  grasping  pressure  of  the  hand. 

We  have  proof,  indeed,  that  even  the  pressure  of  the  hand  will  not 
always  produce  the  desired  effect : but  other  means  are  in  our  pow’er, 
efficacious  and  of  easy  application ; and  of  these,  cold  may  next  be  re- 
sorted to.  A napkin,  soaked  in  vinegar  and  water,  may  be  suddenly  laid 
upon  the  hypogastric  region,  and  the  uterus  will  often  answer  the  stimulus 
immediately.  A succession  of  cold  cloths  may  be  used  in  this  way,  so  as 
to  keep  the  temperature  of  this  part  of  the  person  below  the  standard,  and 
pressure  may  be  used  occasionally  at  the  same  time.  Should  the  bleed- 
ing, however,  still  continue,  and  the  faintness  increase  rather  than  dimi-* 
nish,  the  means  I next  adopt  (and  sometimes  this  is  much  more  useful 
than  any  other  mode  of  applying  cold)  is  dashing  a quantity  of  cold  water 
upon  the  lower  part  of  the  denuded  abdomen.  This  may,  perhaps,  appear 
a rough,  and  neither  a very  refined  nor  very  delicate  mode  of  treatment; 


H JE  M O R R 11  A G E AFTER  REMOVAL  OF  PLACENTA.  389 


but  the  case  is  of  a highly  dangerous  character,  and  all  other  considera- 
tions must  give  way  to  ensuring  the  patient’s  safety.  It  is  an  universal 
observation,  that  a slight  degree  of  cold  applied  suddenly  and  with  a 
shock,  will  produce  a greater  effect  than  a more  intense  one  continued 
for  some  time.  Thus  Gooch* * * §  gives  us  an  instance  in  which  the  uterus 
was  stimulated  to  contract  by  a quantity  of  cold  water,  thrown  suddenly 
from  an  ewer  on  the  abdomen,  although  it  had  not  answered  to  the  appli- 
cation of  ice,  which  had  been  used  previously  for  a considerable  period. 

We  may,  however,  still  be  foiled,  and  must  resort  to  other  measures. 
The  introduction  of  the  hand  into  the  uterine  cavity  may  next  be  put  in 
practice,  and  it  seldom  fails  in  producing  the  contraction  we  desire.  The 
student  may  be  inclined  to  inquire,  then,  why  we  should  not  introduce  the 
hand  immediately  the  haemorrhage  becomes  alarming? — Because  it  is 
better  first  to  adopt  less  harsh  means.  The  introduction  of  the  hand  is 
always  to  be  avoided,  if,  by  any  other  method,  we  can  produce  the  same 
measure  of  good,  without  the  chance  of  injury  : but  yet  there  are  many 
states  that  fully  warrant  even  this  proceeding.  The  coat  must  be  taken  off, 
the  left  hand  and  arm  greased,  and  passed  gently  into  the  uterus,  and  the 
parietes  may  be  stimulated  by  the  fingers  moved  within  it ; at  the  same 
time  that  the  right  hand  grasps  it  externally ; or,  as  Goochf  recommends, 
the  bleeding  vessels  may  be  compressed  with  the  knuckles  within,  while 
the  uterine  tumour  is  pressed  upon  without ; and  by  this  combination  of 
external  and  internal  pressure,  it  is  seldom  that  we  shall  not  succeed  in 
putting  a stop  to  the  discharge.  If  there  be  any  fibrinous  coagula  adhering 
to  the  internal  membrane,  these  must  be  removed  as  cautiously  as  we  should 
separate  the  placenta. 

Some  cases,  however,  will  not  yield  even  to  this  mode  of  treatment,  and 
other  expedients  are  recommended — such  as  injecting  a quantity  of  iced 
water,  vinegar,  or  other  astringents,  into  the  uterus  itself  ;J  which  mode 
of  practice,  however,  I should  fear  might  be  likely  to  induce  inflammation 
of  the  uterine  tissue,  or  of  its  veins.  Ice§  has  also  sometimes  been  intro- 
duced into  the  vagina  with  advantage,  either  naked,  or  wrapped  in  linen 
or  flannel ; before  being  passed  into  the  cavity  it  should  be  held  in  the 
hand  till  the  corners  are  rounded  off.  Again:  it  has  been  recommended 
that  we  should  stuff  the  vagina,  or  even  the  uterus,  with  cloths  steeped  in 
any  astringents  at  hand.||  To  such  an  application,  under  such  circum- 
stances, I have  already  objected ; because  the  blood  is  not  preserved  in 

* Compendium,  by  Skinner,  page  168,  + Op.  Cit.,  page  164. 

t Saxtorph  ; “ New  Method  of  Treating  Haemorrhages  after  Labour.”  Pasta,  in  extreme 
cases,  advises  the  injection  of  alcohol,  or  dilute  sulphuric  or  nitric  acid. — (Gardien,  vol.  iii. 

p.  230.) 

§ Blundell,  p.  466;  Gooch,  p.  167. 


!|  See  Gooch,  p.  168. 


390 


COMPLEX  LABOURS. 


the  woman’s  vessels  by  filling  either  the  vagina  or  the  uterus  ; it  is  escaping 
through  their  orifices,  and  collecting  in  the  uterine  cavity ; and  as  the 
womb,  by  the  presence  of  the  plug,  is  prevented  contracting,  the  very  objecl 
which  we  wish  to  gain  is  defeated  by  our  own  anxious  care.  Compression 
of  the  aorta  has  lately  been  much  extolled  by  Baudelocque,  who  claims  the 
credit  of  the  suggestion.*  There  is  not  much  difficulty  in  moderating  the 
flow  of  blood  through  this  vessel  in  most  women  after  delivery,  especially 
if  they  be  of  spare  habit,  owing  to  the  lax  state  of  the  abdominal  mus- 
cles ; and  in  some  cases  of  after  haemorrhage,  this  proceeding  may  be 
attended  with  fortunate  results.  Dr.  Rigbyf  thinks  the  application  of 
the  child  to  the  mother’s  breast  the  most  efficacious  means  of  procuring 
uterine  contraction  in  this  species  of  haemorrhage.  He  grounds  his  opi- 
nion upon  the  sympathy  which  exists  between  the  two  organs,  and  the 
known  fact  of  the  action  of  sucking  very  generally  inducing  after-pains. 
If  the  trial  can  be  made,  without  disturbing  the  patient  much,  I see  no  ob- 
jection to  its  adoption. 

Of  remedies  acting  through  the  agency  of  the  stomach,  stimuli,  (do- 
mestic or  medicated,)  opium,  the  acids,  and  the  ergot,  are  the  chief  in 
use.  The  cautions  respecting  the  use  of  spirits,  ammonia,  and  other  sub- 
stances which  powerfully  excite  the  arterial  system,  I need  not  here  re- 
peat. They  are  only  admissible— as  long  as  there  is  a chance  of  haemor- 
rhage continuing— when  the  powers  are  sunk  so  low  that  there  is  imme- 
diate and  imminent  danger  present.  I have  stated  that  opium,  in  large 
doses,  is  very  much  extolled  in  cases  of  flooding,  especially  by  Professor 
Burns,  and  Dr.  Stewart,  but  that  I consider  it  a medicine  inadmissible 
unless  the  uterus  have  entirely  contracted,  when  the  danger  of  fresh  bleed- 
ing has  gone  by.{  Opium  certainly  acts  as  a cordial,  lulling  the  irrita- 
bility of  the  patient,  and  producing  a sleep,  or  at  any  rate  a composing? 
stupor ; but  it  also  takes  off  both  muscular  and  uterine  action : it  disables, 
the  uterus,  therefore,  from  contracting,  even  were  it  so  disposed ; and  if 
the  proposition  be  true,  that  on  the  contraction  of  the  uterus  alone  we  are 
to  rely  for  the  patient’s  ultimate  safety,  it  cannot  but  appear  contradictory 
to  resort  to  a medicine  whose  very  action  tends  to  prevent  the  effect  de- 
sired. It  has  been  objected,  that  although  opium,  in  small  quantities, 

* Mem.de  l’Academie  des  Sciences,  January,  1835.  Although  this  might  have  been,  an, 
original  thought  of  Baudelocque,  the  practice  had  been  pursued  ten  years  before  by  Ulsamer, 
(see  Lancet,  July  20th,  1839  ;)  and  I myself  had  employed  it  long  before  Baudelocque’s  memoir  . 
was  published.  A proposal  to  the  same  effect,  by  Trehan,%ill  be  found  in  vol.  xxxiii.  of  thV 
Journal  Compl.  du  Diet,  des  Sciences  M6d.,  p.  367. 

t Med.  Gazette,  vol.  xiii.  p.  785,  and  vol.  xiv.  p.  335.  He  gives  cases  in  illustration ; and 
states  that  his  attention  was  first  drawn  to  the  subject  by  an  observation  in  Professor  Carus’s 
Gynakologie. 

t Page  347. 


TRANSFUSION. 


391 


takes  away  uterine  action,  yet,  in  large  doses,  it  produces  the  very  oppo- 
site  result,  and  excites  contraction.  This  proposition  is  at  variance  with 
common  sense,  with  all  analogy  of  the  actions  of  other  drugs,  and  at  least 
with  my  experience.  I have  often  seen,  at  the  commencement  of  labour, 
uterine  action  suspended  by  what  would  be  considered  a large  dose  of 
opium ; and  if  the  same  quantity  will  take  away  action  at  the  beginning 
of  the  process,  is  it  reasonable  to  suppose  it  will  excite  it  at  the  termina- 
tion ? — But  it  may  be  said  the  experience  of  practitioners  of  eminence 
proves  the  value  of  opium  in  the  case  under  consideration  ; and  that  there 
is  no  reasoning  against  experience.  I by  no  means  deny  that  many  pa- 
tients have  done  well  after  the  administration  of  large  doses  of  opium;  but 
that  circumstance  does  not  prove  that  the  drug  was  the  agent  of  their 
preservation.  I should  be  inclined  to  attribute  the  recovery  to  other 
causes,  independently  of  the  exhibition  of  the  medicine.  I strongly 
recommend  opium  in  large  doses  and  the  solid  form,  in  those  cases  of 
irritability  produced  by  a loss  of  blood  which  had  previously  taken  place; 
but  that  only  when  the  uterus  is  contracted  and  the  danger  from  flooding 
is  past. 

We  should  act  unwisely  to  trust  much  to  any  of  the  mineral  acids  in 
these  dangerous  cases,  but  they  may  be  resorted  to  in  combination  with 
the  use  of  other  means,  and  generally  act  as  grateful  refrigerants.  The 
ergot  seems  to  be  indicated,  as  the  grand  object  is  to  produce  uterine 
contraction : it  may  be  combined  with  an  acid.  I have  witnessed  many 
cases  of  after-haemorrhage,  in  which  it  appeared  to  have  been  given  with 
decided  advantage. 

Transfusion. — Our  last  resource  is  the  transfusion  of  blood  into  the 
system  of  the  dying  patient, — a means  deemed  by  some  most  powerful  in 
arresting  the  vital  spirit,  even  as  it  flutters  with  tremulous  delay  upon  the 
lip.  To  Dr.  Blundell  is  due  the  merit  of  having  restored  the  practice,  of 
advocating  its  adoption  with  all  the  force  of  his  powerful  mind,  and 
proving  its  efficacy  both  by  reasoning  and  experiment.  But  transfusion 
can  be  of  little  use,  unless  contraction  have  taken  place  in  the  uterine 
parietes.  It  is  evident  that,  while  the  vessel  remains  patulous,  the  more 
we  excite  the  arterial  system,  the  more  likely  is  the  flooding  to  continue, 
as  is  demonstrated  in  the  -use  of  the  ordinary  stimulants.  If,  then,  by 
Infusing  blood  while  the  uterine  structure  remains  flaccid,  we  cause  the 
hea^t  to  beat  more  forcibly,  the  fluid  will  again  exude  through  the  open 
vessels; — and  we  might  inject  ad  infinitum , — the  arteries  emptying  them- 
selves as  the  veins  become  distended.  But  the  case  is  very  different  when 
we  have  closed  the  vessels  through  which  the  blood  escapes ; it  is  then 
retained  in  the  body,  forms  a part  of  the  circulating  current,  revives  the 
patient  by  its  action  on  the  brain,  and  restores  her  from  temporary  death 


392 


COMPLEX  LABOURS. 


to  life.  I would  restrict  the  practice  of  transfusion,  then,  to  those  cases 
in  which  there  is  no  chance  of  the  blood  again  escaping  ;* * * §  and  I think  it 
would  be  most  useful  when  the  placenta  has  been  removed — when  the 
uterus  has  contracted — when  the  haemorrhage  that  had  caused  the  depres- 
sion has  ceased — but  when  the  patient  remains  fainting  and  in  danger, 
unable  to  be  rouged  by  stimuli  taken  into  the  stomach,  and  without  a 
well-grounded  hope  of  restoration  being  effected  by  her  own  proper 
powers. 

In  such  cases  I have  little  doubt  that  transfusion  may  be  most  valuable; 
but  if  it  becomes  a common  practice,  I am  persuaded  it  will  often  be 
employed  unnecessarily.  This  opinion  I form  from  having  seen  many 
women  recover  without  any  blood  being  transfused  into  their  system, 
who  seemed  scarcely  to  have  a chance  of  life.  If  in  these  cases  the 
means  under  consideration  had  been  used,  the  credit  of  the  recovery 
would  have  been  given  to  the  operation,  and  strong  arguments  might 
have  been  adduced  in  favour  of  the  propriety  of  the  measure.f 

It  is  astonishing  how  tenacious  of  life  some  systems  appear  under  ute- 
rine haemorrhage,  and  how  easily  others  will  let  it  glide  away.  The 
necessity,  then,  of  such  means  in  any  particular  case,  will  be  a question 
of  the  greatest  nicety.  If  employed  while  haemorrhage  is  going  on 
actively,  it  will  be  useless;  if  delayed  until  the  breathing  has  quite  ceased,; 
it  cannot  be  expected  to  be  followed  by  restoration ; if  commonly  prac- 
tised,  it  will  many  times  be  resorted  to  unnecessarily. 

Mode  of  performing  transfusion. — Blundell, J with  much  ingenuity,  has 
contrived  an  instrument,  named  by  him  the  impellor , by  which  the  blood 
may  be  at  once  transfused  from  one  system  to  the  other,  without  being 
obliged  to  stagnate  in  a vessel ; but  as  this  is  rather  a cumbrous  machine, 
and  difficult  to  adjust,  and  especially  as  the  same  enlightened  physiologist 
has  proved  beyond  dispute  that  the  vital  fluid  loses  little  or  none  of  its, 
valuable  properties  by  being  collected  in  a cup,  absorbed  by  a syringe, 
and  afterwards  injected, — provided  no  time  be  unnecessarily  wasted,— I 
shall  merely  describe  the  readiest  mode  of  performing  the  operation  by  a 
common  syringe.  The  instrument  should  be  of  brass,  tinned  inside  capa- 
ble of  containing  between  two  and  three  ounces,  perfectly  air-tight,  and 
clean  from  oil.§  One  or  two  persons, — males  in  preference  to  females, 

* An  exception  should  be  made  in  favour  of  placental  presentations,  as  mentioned-  at 
page  347. 

t See  Hamilton,  p.  339  ; Davis,  p.  1066  ; and  Velpeau,  edit,  Brux.  p.  494. 

t Physiol,  and  Patholog.  Researches,  1824. 

§ A very  simple  and  ingeniously  contrived  syringe  for  the  purpose  of  this  operation  will  be 
found  described  and  depicted  in  Waller’s  edition  of  Denman ; also  in  the  Lancet  for  Oct.  31, 
1840,  where  there  is  a highly  valuable  case,  and  some  judicious  remarks  by  Mr.  Lane.  I 


TRANSFUSION. 


393 


from  their  less  liability  to  faint, — being  in  readiness  to  supply  the  blood, 
one  of  the  patient’s  veins  at  the  bend  of  the  elbow  must  be  laid  bare  to 
the  extent  of  an  inch,  and  divested  of  its  cellular  web ; an  aperture  must 
then  be  made  into  it  of  rather  more  than  a line  in  length.  The  blood 
must  be  drawn  from  one  of  the  bystanders  in  a full  stream ; about  three 
ounces  must  be  received  into  a conical  cup  or  tumbler,  and  absorbed  as 
soon  as  it  is  collected : the  nozzle  of  the  syringe  must  be  raised  perpendi- 
cularly, and  the  piston  slowly  propelled  upwards,  to  expel  any  air  that 
might  have  passed  into  the  instrument : its  point  must  afterwards  be  in- 
serted in  the  aperture  formed  in  the  vein,  and  the  blood  slowly  propelled 
towards  the  heart.  No  ligature  need  be  put  upon  the  patient’s  arm  below 
the  wound ; but  the  vein  may  be  secured  by  passing  a blunt-pointed  probe 
entirely  under  it,  having  dissected  it  away  from  its  surrounding  attach- 
ments; and  this  particularly,  lest  blood  should  escape  from  the  incision, 
and  embarrass  the  operator.  The  chief  delicacy  of  the  operation  consists 
in  regulating  the  quantity  used,  and  in  adjusting  the  velocity,  with  which 
it  is  injected,  to  the  diminished  power  of  the  arterial  system.  Jf  we  throw 
it  in  with  too  much  force,  we  may  choke  the  heart,  and  death  will  be  the 
consequence : if,  on  the  other  hand,  we  are  too  tardy  in  our  operations, 
the  blood  may  partially  coagulate,  and  be  rendered  unfit  for  the  purposes 
of  life.  We  may  inject  a second,  third,  and  fourth  syringe  full,  delibe- 
rately watching,  between  each,  the  effect  produced.  Twelve  or  fourteen 
ounces  will  most  probably,  at  the  highest  average,  be  sufficient,  if  any 
advantage  is  to  result  from  our  endeavours:  for,  since  we  know  that, 
although  a patient  will  sometimes  bear  a large  loss  of  blood  with  com- 
parative impunity,  the  additional  loss  of  a very  few  ounces  more  mav 
irrecoverably  depress  her,  so  we  may  reasonably  infer  that  a small 
quantity  added  to  the  system,  after  a great  diminution  has  been  sustained, 
will  be  sufficient  to  raise  it  to  the  necessary  point — unless,  indeed,  the 
nervous  energy  be  too  much  sunk  to  be  roused  by  any  means  that  human 
ingenuity  could  devise. 

I have  directed,  that  if  transfusion  appear  necessary,  human  blood 
should  be  used  for  the  purpose ; and  this  recommendation  is  founded  on 
experiments  first,  in  modern  times,  performed  by  Dr.  Leacock,  of  Bar- 
badoes,  and  made  known  through  the  medium  of  his  inaugural  thesis, 
printed  in  Edinburgh  in  1817 ; and  afterwards  frequently  repeated  and 
varied  by  Dr.  Blundell.**.  These  experiments  prove  that  the  blood  of  one 


have  not  thought  it  necessary  to  give  a delineation  of  this  instrument,  nor  to  point  out  the 
mode  of  using  it,  as  that  copy  of  Denman  is  well  known,  and  as  I presume  the  talented 
periodical  I have  referred  to  is  in  the  hands  of,  or  at  least  accessible  to,  every  practitioner. 

* Op.  Cit..  p.  81,  et  seq.  Leacock,  in  his  experiments  on  the  dog,  used  sheep’s  blood; 
Blundell  that  of  the  human  subject. 

50 


394 


COMPLEX  LABOURS. 


genus  of  animals  is  unfit  to  carry  on  the  functions  of  life,  when  injected 
in  any  considerable  quantity,  into  the  system  of  an  individual  of  another 
genus.  If  human  blood,  or  that  of  sheep,  for  instance,  be  injected  into  the 
veins  of  a dog,  after  the  animal  has  been  bled  to  syncope,  resuscitation 
for  a time  occurs;  but  it  is  not  lasting — the  powers  soon  begin  to  droop, 
and  after  a period,  varying  from  a few  minutes  to  some  hours  or  days  of 
languid  existence,  death  takes  place.  Thus,  then,  we  must  never  think 
of  employing,  for  the  purpose  in  question,  any  other  blood  than  that  de- 
rived from  the  human  subject. 

Management  of  a patient  after  dangerous  haemorrhage. — When  a wo- 
man has  suffered  haemorrhage  to  any  dangerous  extent,  although  the 
uterus  may  have  become  firmly  contracted,  and,  to  her  own  feelings,  she 
is  comparatively  comfortable,  yet  she  must  by  no  means  be  considered 
safe  for  many  hours ; because  the  organ  may  again  relax,  and  with  a 
return  of  the  relaxation  there  may  be  a return  of  the  bleeding.  It  be- 
hoves us,  then,  to  guard  against  such  a possibility ; and  the  best  mode  of 
prevention  is  to  keep  her  perfectly  quiet,  to  allay  irritability,  and  solicit 
sleep  by  a moderately  large  dose  of  opium,  and  to  sustain  her  by  a fre- 
quent supply  of  fluid  nourishment  in  small  quantities.  Strict  injunctions 
must  consequently  be  given  that  she  should  not  be  moved  for  many  hours. 
In  ordinary  cases,  after  labour  we  require  that  an  hour  and  a half,  or  two 
hours,  should  elapse  before  the  patient  is  placed  in  bed  in  the  position  she 
is  to  retain,  and  her  linen  changed  ; but  after  haemorrhage,  wre  shall  fre- 
quently find  it  necessary  to  keep  her  in  the  same  position  for  eight,  ten,  or 
twelve  hours,  or  even  longer.  A bandage  may  be  applied,  but  beyond 
that  no  alteration  should  be  made  in  her  person.  Many  cases  are  on 
record,  where  a patient,  having  suffered  haemorrhage,  has  been  placed  in 
a sitting  posture,  for  the  purpose  of  having  her  person  made  more  com- 
fortable, and  has  fallen  down  dead  upon  the  bed ; others,  where  moving 
from  one  side  of  the  bed  to  the  other  has  produced  syncope,  and  even 
death ; and  some,  where  the  same  fatal  consequence  has  followed  the 
slight  exertion  of  raising  the  head  above  the  level  of  the  shoulders : so  that 
we  cannot  be  too  cautious  in  allowing  the  least  disturbance.  The  room 
may  be  darkened  and  well  ventilated  ; opium  may  be  given,  with  a little^ 
stimuli,  if  necessary ; and  such  nutrient  fluids  as  are  most  easy  of  digest 
tion,  should  be  exhibited  at  regular  and  short  intervals. 

Effects  of  the  loss  of  blood. — There  are  many  distressing  symptoms 
consequent  on  the  loss  of  blood,  independently  of  fainting.  Some  of  these 
appear  soon,  and  are  comparatively  evanescent ; others  do  not  occur  for 
some  time,  being  more  remote,  but  more  permanent.  Of  the  latter  kind 
are  cachexia,  wastings,  purgings,  dyspepsia,  dropsies, — especially  an 
cedematous  state  of  the  legs  and  feet.  Such  affections  are  to  be  attributed 


EFFECTS  OF  THE  LOSS  OF  BLOOD. 


395 


to  the  balance  of  the  circulation  being  destroyed,  by  the  sudden  abstrac- 
tion of  so  much  blood  from  the  circulating  system. 

The  loss  of  blood  will  sometimes  excite  dormant  morbid  actions, 
which  may  terminate  in  organic  disease,  where  there  is  a predisposition 
to  its  formation.  I have  seen  two  cases  in  which  phthisis  itself  seemed 
to  be  called  forth,  in  its  direst  form,  as  a consequence  of  violent  haemor- 
rhage, no  symptoms  of  diseased  lungs  having  previously  existed. 

The  loss  of  tone  in  the  system  generally,  is  best  relieved  by  sending  the 
patient  into  the  country,  to  the  sea  side,  or  some  chalybeate  spring,  enjoin- 
ing regular  hours,  regular  exercise,  regular  nourishing  diet,  with  gentle 
stimuli  and  tonic  medicines, — provided  there  be  no  local  affections,  or 
any  contra-indicating  symptoms.  CEdema  of  the  legs  will  most  likely 
disappear  spontaneously  ; if  an  accumulation  of  water  take  place  in  the 
abdominal  cavity,  diuretics  or  elaterium  may  procure  its  removal,  or  an 
operation  may  be  required.  The  purgings  produced  by  an  irritable  state 
of  the  mucous  membrane,  so  frequent  as  a consequence  of  a copious  loss 
of  blood,  may  be  relieved  by  chalk,  opium,  rice,  and  nourishing  diet.  The 
aphthous  state  of  the  mouth  accompanying  the  purgings  will  also  often 
yield  to  the  same  treatment.  Both  these  symptoms,  however,  are  most 
likely  to  be  alleviated  by  sending  the  woman  into  a purer  air.  It  is  com- 
monly observed  by  practitioners  in  crowded  cities,  that  the  diarrhoea  has 
subsided  immediately  on  removal,  although  it  had  not  given  way  in  the 
least  degree  to  the  exhibition  of  the  most  approved  medicines. 

Re-action  after  flooding. — The  symptoms  which  appear  immediately 
after  flooding,  when  the  first  effects  of  fainting  are  gone  off,  are  those  '6f 
re-action  and  nervous  irritability  in  an  extreme  degree.  When  the  sys- 
tem is  deprived  of  a large  quantity  of  blood,  the  circulation  is  carried  on 
in  a much  more  rapid  manner,  that  the  increased  velocity  may  compen- 
sate for  the  diminution  in  quantity;  and  in  proportion  as  the  quantity  is 
diminished,  will  the  velocity  be  increased. 

This  re-action  is  attended  with  fever;  quick,  small,  sharp,  jerking,  and 
sometimes  a wiry,  at  others  a compressible  pulse ; increased  heat  and  dry- 
ness of  skin ; shrivelled  features ; dryness  of  the  mouth,  and  a parched  and 
pinched  state  of  the  nose  and  lips;  a diminution  in  all  the  secretions;  de- 
Mre  for  fluid,  and  dislike  to  solid  food;  intolerance  of  light  and  sound; 
inability  to  sleep,  and  most  distressing  pain  in  the  head.  Palpitations  are 
often  present ; so  also  are  panting,  dyspnoea,  and  a degree  of  hurry  and 
alarm  on  waking  from  a doze,  or  being  suddenly  disturbed. 

The  pain  in  the  head  is  almost  universal  after  haemorrhage,  and  is  very 
characteristic.  It  is  described  as  being  similar  to  the  thumping  of  a small 
hammer  within  the  skull,  or  the  ticking  of  a clock ; sometimes,  but  more 
rarely,  it  resembles  the  roaring  of  the  sea,  or  singing  of  a kettle.  Every 


396 


COMPLEX  LABOURS. 


movement  of  the  head  is  attended  with  great  uneasiness ; and  if  raised 
from  the  pillow,  a sense  of  fainting  supervenes.  I have  little  doubt  that 
th  is  sensation  of  thumping  arises  from  the  column  of  blood  being  lessened 
i n diameter,  and  the  arteries  not  being  sufficiently  distended  by  their  con- 
tents. As  these  vessels  are  highly  elastic,  their  calibre  contracts  in  pro- 
portion to  the  decreased  quantity  of  blood  that  they  contain.  When  they 
are  fully  filled,  and  their  coats  are  duly  distended,  they  propel  the  blood 
onward  with  but  slight  effort;  but  when  partially  emptied,  so  that  the 
natural  and  healthy  agreement  between  their  capacities  and  the  measure 
of  their  contents  is  disturbed,  they  are  compelled  to  beat  violently,  in  order 
to  carry  on  the  circulation ; and  this  forcible  contraction  propagates  an 
increased  jerk  to  the  fluid.  Most  probably  this  state  pervades  the  whole 
body ; but  it  is  only  perceived  in  the  brain,  in  consequence  of  the  struc- 
ture and  peculiar  sensibility  of  that  tender  organ.* 

Treatment. — If  we  bear  in  mind  that  the  cause  of  the  distressing  symp- 
toms is  referable  to  the  decreased  quantity  of  blood  circulating,  and  its 
augmented  velocity,  dependent  on  the  diminution  in  its  quantity,  we  shall 
never  be  much  at  a loss  in  directing  our  treatment.  Our  object  is  to 
diminish  the  present  irritability— to  alleviate  the  febrile  symptoms — to 
remove  the  distracting  headach — to  preserve  as  much  as  possible  the 
remaining  power — and  gradually  to  add  to  the  mass  of  circulating 
fluid. 

With  the  latter  view,  nutritious  diet  must  be  frequently  administered; — 
sago,  arrowroot,  milk,  jelly,  and  strong  broths,  in  as  large  a quantity  as 
the  stomach  will  digest.  To  diminish  the  irritability  of  the  system,  and 
moderate  excessive  action,  saline  medicines  may  be  given,  either  in  effer- 
vescence or  not ; cold  sponging  may  be  employed  to  the  hands,  arms,  and 


* This  beating  pain  is  so  very  general,  that  we  may  often  at  once  commend  ourselves  to 
the  confidence  of  our  patient,  by  the  pertinence  of  our  questions  regarding  it.  There  is  no- 
thing in  the  whole  range  of  the  practice  of  medicine  which  attracts  the  attention  of  a patient 
so  much,  or  so  forcibly  convinces  him  that  his  physician  understands  the  nature  of  the  dis- 
ease under  which  he  labours,  as  an  accurate  description  of  the  painful  sensations  he  is  suffer- 
ing. For  our  own  sake,  then,  as  well  as  his,  it  is  desirable  in  our  general  conduct  at  the 
side  of  a sick-bed,  that  we  should  habituate  ourselves  not  to  hurl  a number  of  random  ques- 
tions at  the  patient,  but  only  to  put  such  as  appear  pertinent  to  the  case,  and  are  likely  at 
once  to  strike  his  notice.  The  confidence  of  the  sick,  indeed,  is  a heavy  weapon  in  the  hands- 
of  his  physician;  it  is  sometimes  more  serviceable  than  the  whole  combined  armament  of  the1^ 
Materia  Medicq.  These  observations  apply  eminently  to  the  case  under  consideration.  If 
we  see  a woman  blanched,  with  her  skin  of  a waxen  paleness;  if  we  find  a jerking,  bounding, 
haemorrhagic  pulse,  and  learn  that  a few  days  before  she  has  suffered  a large  loss  of  blood, 
we  may  be  almost  assured  that  this  peculiar  pain  in  the  head  is  present.  The  simple  inquiry, 
then,  addressed  to  her,  “ Whether  she  is  not  suffering  under  a violent  beating,  like  that  of  a 
small  hammer,  within  the  skull  ?”  will  often  of  itself  be  sufficient  to  inspire  her  with  confi- 
dence. 


EFFECTS  OF  THE  LOSS  OF  BLOOD. 


397 


face ; and  opium  may  be  prescribed  in  tolerably  large  doses.  Both  the 
mental  and  corporeal  irritability  produced  by  a loss  of  blood,  is  better 
alleviated  by  opium  than  any  other  remedy : and  although  as  a principle 
we  avoid  opium  when  much  headach  is  present,  in  this  particular  affec- 
tion the  drug,  either  alone,  or  combined  with  salines  or  ipecacuanha,  will 
often  be  found  most  serviceable.  Nevertheless,  it  is  not  to  be  expected 
that  any  medical  means  will  rapidly  remove  the  cerebral  distress;  but 
it  will  generally  be  observed,  that  as  fresh  blood  is  formed  by  the 
assimilation  of  nourishment,  all  the  symptoms  will  gradually  subside.  I 
cannot  help  thinking,  indeed,  that  if  no  medical  treatment,  beyond  proper 
attention  to  the  bowels,  were  employed — if  nothing  were  exhibited  but 
mild  nourishment  in  small  quantities,  at  regular  intervals,  the  symptoms 
would  of  themselves  disappear;  and  I am  persuaded,  that  in  no  few 
instances  medical  interference  has  been  of  decided  injury. 

I would  caution  the  student  against  using  any  means  which  are  likely 
to  diminish  the  quantity  of  blood  circulating  in  the  system  ; and  therefore 
all  powerful  evacuant  remedies  must  be  avoided,  particularly  bleeding. 
Generally  nothing  can  be  more  injurious  than  the  bold  use  of  the  lancet 
under  this  state  of  reaction,  consequent  on  the  loss  of  blood ; and  no  treat- 
ment can  be  more  unphilosophical ; and  yet  I have  known  venesection 
repeatedly  resorted  to.  Taking  blood,  indeed,  will  for  a time  almost  always 
relieve  the  pain ; but  the  alleviation  is  merely  temporary,  it  only  remains 
as  long  as  the  patient  continues  faint;  reaction  soon  occurs  in  a still 
greater  degree  than  before,  and  an  aggravation  of  the  symptoms  is  the 
consequence.  It  is  not  reasonable  to  suppose  that  this  peculiar  headach 
arises  from  undue  determination  of  blood  to  the  brain ; but  more  probable 
that  it  is  produced  rather  by  the  vessels  being  too  empty.  For  this  rea- 
son, also,  I should  avoid  leeching  and  blistering  the  head,  or  its  neigh- 
bourhood. If,  indeed,  instead  of  a pale  exsanguined  countenance, — which 
is  almost  invariably  present, — there  should  be  a turgid  and  suffused  face, 
indicating  an  extraordinary  fulness  of  the  veins  of  the  skin,  I should  pre- 
sume the  same  state  to  have  taken  place  within  the  skull,  and  should  then 
apply  leeches  pretty  freely,  or  use  other  means  to  relieve  the  surcharged 
vessels.  I should  object  also  to  violent  purging  ; for  I think  I have  seen 
two  or  three  instances  where  this  practice  appeared  to  aggravate  the 
^symptoms.  It  is  certainly  proper  to  take  care  that  the  lower  part  of  the 
intestinal  canal  should  thoroughly  empty  itself  daily,  but  not  to  keep  up 
• by  medicine  such  a constant  irritation  on  the  mucous  membrane  as  will 
produce  a very  much  increased  secretion,  and  a copious  drain  from  the 
system  generally.  A slight  purgative  may  be  given  every  day,  more  with 
the  view  of  stimulating  the  sluggish  action  of  the  intestines,  than  of  pro- 
curing a number  of  watery  stools. 


398 


COMPLEX  LABOURS. 


Cold  applications  to  the  head,  and  especially  ice,  will  often  relieve  the 
pain  in  a great  degree  during  the  time  they  are  being  used ; but  it  returns 
when  they  cease  to  be  applied.  There  cannot  exist  any  objection  to  the 
application  of  cold ; it  must  do  good  if  it  can  bring  freedom  from  suffering  ; 
and  it  can  produce  no  injurious  effects  subsequently,  as  powerful  evacuants 
may  do.* 

We  shall  be  most  successful,  then,  by  avoiding  powerful  evacuants,  yet 
regulating  the  bowels  daily,  by  the  exhibition  of  saline  medicines  and 
Dover’s  powder,  or  small  doses  of  ammonia  with  hyoscyamus,  by  the 
application  of  cold  to  the  head,  by  sponging  the  face,  arms,  and  hands, 
with  vinegar  or  cold  water, — provided  there  be  increased  heat  of  skin, — 
by  admitting  fresh  air,  enjoining  perfect  quiet,  soothing  irritability,  solicit- 
ing sleep,  and  by  a frequent  supply  of  mild  fluid,  and  nutritive  food. 


2d.  LABOURS  COMPLICATED  WITH  CONVULSIONS. 

An  attack  of  puerperal  convulsions  is  one  of  the  most  frightful  accidents 
that  can  happen  to  a patient  under  labour. 

A convulsive  paroxysm  during  labour  may  occur  under  two  extreme 
states  of  system  diametrically  opposed  to  each  other ; the  one,  in  which 
the  cerebral  vessels  are  inordinately  distended  with  blood  ; and  the  other, 
when  they  have  been  drained  almost  empty,  as  in  the  case  of  excessive 
haemorrhage : and  it  is  a curious  fact,  that  the  two  perfectly  opposite 
states,  viz.  too  great  a fulness  of  the  vessels,  and  too  great  emptiness,  will 
produce,  in  this  respect,  exactly  the  same  phenomena.-)- 

I have  already  mentioned,  that  the  occurrence  of  a convulsive  seizure, 
in  a patient  who  has  suffered  violent  haemorrhage,  is  to  be  regarded  as  a 

* The  young  practitioner  may  consult  with  great  advantage  Dr.  Marshal  Hall’s  Treatise 
on  the  Effects  of  Loss  of  Blood  : the  profession  is  much  indebted  to  him  for  his  means  of  diag- 
nosis between  the  affections  of  the  different  viscera,  particularly  the  heart  and  brain,  produced 
by  excessive  depiction,  and  somewhat  similar  symptoms  the  result  of  inflammatory  action. 

t It  is  almost  universally  observed,  that  when  an  animal  is  bled  to  death,  the  last  act  of 
life  is  a most  violent  convulsion  of  the  voluntary  muscles.  Andral  says,  In  at  attack  of 
convulsions,  the  brain  is  equally  effected  by  an  over-abundant,  or  too  sparing  a flow  of  blood 
to  the  head.”  (Med.  Gazette,  vol.  xiii.  p.  106.)  Some  pathologists,  indeed,  have  regarded  it 
as  “improbable  that  any  state  of  things  should  materially  augment  or  diminish  the  actual  ■ 
amount  of  fluids  within  the  cranium,”  in  consequence  of  the  brain  being  perfectly  enclosed  J 
within  a bony  case,  and  removed  from  the  influence  of  atmospheric  pressure. — (Reviewer  of 
Abercrombie’s  work  on  the  Brain.  Med.  Chirurg.  Review,  vol.  ix.  p.  85.)  The  talented  author 
just  mentioned  seems  to  entertain  the  same  view.  So  also  Clutterbuck,  (Cyclop,  of  Prac. 
Med.,  vol.  i.  p.  125,  art.  Cerebral  Apoplexy.)  I am  inclined  to  think,  that  when  haemorrhage 
to  any  extent  takes  place,  the  cerebral  vessels  participate,  in  no  small  degree,  in  the  general 
inanition  of  the  circulatory  system. 


PUERPERAL  CONVULSIONS. 


399 


highly  dangerous,  and  frequently  a mortal  symptom.  Such  cases,  how- 
ever, are  not  to  be  looked  upon  as  true  puerperal  convulsions : this  term 
should  be  restricted  to  the  disease  next  to  be  described. 

Period  at  which  they  occur. — The  true  puerperal  convulsions  may  oc- 
cur at  any  period  of  the  latter  half  of  pregnancy,  or  in  any  stage  of  labour ; 
they  not  unusually  first  make  their  attack  many  hours  even  after  the  child 
is  born,  and  the  placenta  expelled ; when  the  process  is  popularly  consi- 
dered as  completed.  We  generally  meet  with  them,  however,  during  the 
last  few  weeks  of  utero-gestation,  or  the  first  stage  of  labour,  previously  to 
the  entire  dilatation  of  the  os  uteri.  At  other  times,  but  more  rarely,  they 
occur  when  the  head  is  pressing  on  the  outlet  of  the  pelvis,  and  distending 
the  perineum — when  the  uterus  has  been  acting  excessively  strongly,  and 
the  labour  is  somewhat  lingering.  The  great  bodily  exertion  consequent 
on  the  parturient  efforts  may,  in  such  a case,  have  much  influence  in  their 
production.  Occasionally,  indeed,  convulsions  appear  early  in  pregnan- 
cy ; and  Perfect  gives  us  two  cases*  in  which  they  attacked  the  patient 
before  quickening. 

Universal  liability  to  them. — These  convulsions  may  assail  women  of 
all  ages,  and  of  all  kinds  of  constitution ; women  with  their  first  child,  as 
well  as  those  who  have  borne  many  ; but  they  by  far  most  frequently  ac- 
company first  labours  ;f — and  the  kind  of  patient  most  obnoxious  to  their 
attack  is  the  stout,  florid,  robust  woman,  of  strong  muscular  fibre,  with  a 
thick  set  form,  and  short  thick  neck — just  such  a person  as  would  be  con- 
sidered predisposed  to  apoplexy.  But  the  most  delicate  and  slim  female 
is  by  no  means  exempt  from  the  danger  of  a convulsive  seizure.  There 
is  little  doubt  that  a naturally  excessive  sensitiveness  of  the  nervous  sys- 

* Cases  in  Midwifery,  XLV.  and  XLVI. 

t Women  in  their  first  pregnancy,  and  those  who  carry  more  than  one  infant  in  utero,  are 
most  liable  to  convulsions,  (Hamilton,  Pract.  Obs.,  p.  356.  See  also  Denman,  chap.  xvi.  sect. 
2,)  &c.  Out  of  19  cases  recorded  by  Dr.  Joseph  Clarke,  16  were  first  births.  (Collins,  p.  200 
note.)  Of  36  by  Merriman,  28  were  first  births,  (p.  141.)  Of  30  by  Collins,  29  were  first 
births,  (p.  200.)  Of  26  by  my  father,  (part  2,)  in  four  no  mention  is  made  as  to  whether  they 
were  first  pregnancies;  but  of  the  22  remaining,  15  were  so;  three  were  not,  the  women  being 
at  full  time ; four  were  not,  the  births  being  under  seven  months.  These  cases  were  selected 
by  him  out  of  a great  number,  either  because  of  their  dangerous  symptoms,  or  to  exemplify 
some  point  of  practice,  without  reference  to  their  being  first  or  subsequent  births.  Of  59 
cases  which  I have  myself  attended,  17  occurred  before  labour  was  instituted,  28  during  the 
process,  and  14  after  its  termination.  There  were  three  cases  of  twins:  45  were  first  births; 
13  of  the  women  died;  of  the  children,  41  were  expelled  naturally  by  the  head;  6 were  deli- 
vered  by  craniotomy;  6 by  the  forceps;  5 by  turning;  and  4 presented  with  the  breech  ; 23 
of  these  only  were  born  alive,  and  of  these  cases,  in  12  the  convulsions  took  place  after  deli- 
very.  One  patient  was  attacked  nine  days  afler  labour,  another  ten,  a third  seven ; the  convul- 
sions ceased  for  a week ; she  then  had  another  series  of  fits,  of  which  she  died;  and  a fourth  18 
days  subsequently.  This  is  the  longest  period  I have  known  intervene  between  the  birth,  and 
an  accession  of  this  dangerous  disease. 


400 


COMPLEX  LABOURS. 


tem  may  predispose  to  the  disease  ; and  I have  traced  an  attack,  more 
than  once,  to  originate  from  mental  emotion,  particularly  grief,  despon- 
dency, or  other  depressing  passions. 

Analogy  to  apoplexy  and  epilepsy.— Puerperal  convulsions  are  more  al- 
lied to  apoplexy  than  any  other  disease  of  the  body,  inasmuch  as  they 
usually  depend  upon  exactly  the  same  causes.  There  is  also  an  analogy 
in  respect  to  the  stertor  and  stupor*  which  form  prominent  features  in  both 
diseases.  They  would  likewise  seem  to  bear  some  resemblance  to  epilepsy 
from  the  violent  spasmodic  paroxysms  which  constitute  the  most  striking 
symptom  of  puerperal  convulsions.  The  disease  is  unlike  apoplexy,  however, 
because  in  common  apoplexy  we  seldom  have  the  convulsive  fits,  and  sel- 
dom or  never  is  permanent  paralysis  produced  as  a consequence  of  puer- 
peral convulsions.* 

Again,  it  is  seldom  that  in  epilepsy  the  convulsive  paroxysms  follow 
each  other  so  rapidly  as  they  do  under  an  attack  of  the  disease  we  are 
now  considering  ; but  they  have  a tendency  to  return  at  different  periods 
throughout  the  whole  or  a considerable  portion  of  life.  This  latter  obser- 
vation, however,  does  not  apply  to  puerperal  convulsions ; nor  is  there  any 
aura  epileptica  observable  in  this  affection.  Upon  the  whole,  it  appears 
to  me  that  the  convulsions  of  the  puerperal  state  bear  much  more  resem- 
blance to  apoplexy  than  to  epilepsy,  because  they  are  produced  by  exactly 
similar  causes, — those  causes,  indeed,  acting  on  the  system  under  peculiar 
circumstances,— and  because  they  are  relieved  by  exactly  the  same  means. 

I look  upon  a case  of  puerperal  convulsions  to  be,  in  fact,  one  of  apo- 
plexy, only  that  we  have  superadded  to  the  common  apoplectic  phenome- 
na violent  spasmodic  contractions  ;f  and  this  symptom  is  dependent  upon 
the  irritable  and  excitable  state  of  the  nervous  system  always  in  a greater 
or  less  degree  accompanying  pregnancy  and  parturition.  We  can  readily 
imagine  that  in  a highly  excitable  state  of  the  nervous  system,  any  irrita- 
tion which  the  brain  might  suffer  would  be  more  likely  to  produce  convul- 


* However  desirable  and  proper  it  may  be,  for  the  purpose  of  carrying  on  a system  of  mi- 
nute nosological  arrangement,  to  divide  puerperal  convulsion  into  different  species— such  as  te- 
tanic,  cataleptic,  hysteric,  epileptic,  apoplectic,  &c.— it  appears  to  me  that  such  a mode  of 
treating  the  subject  tends  only  to  confuse  the  student,  and  divert  his  mind  from  the  chief  ob- 
ject to  which  it  should  be  directed, — the  value  of  the  various  curative  means  which  we  have 
it  in  our  power  to  apply.  Dewees  classes  them  under  three  heads,  the  epileptic , apoplectic , 
and  hysteric.  Baudelocque  arranges  them  under  the  titles  of  tetanus , epilepsy , and  catalepsy. 
Merriman  styles  them  dystocia  epileptica  ; while  Velpeatf  and  Desormeau  prefer  the  general 
term  eclampsia.  , 

t “ When  a woman  in  labour  is  seized  with  convulsions,  attended  with  stertor,  frothing  at 
the  mouth,  lethargy,  or  total  insensibility,  she  may  be  considered  as  suffering  an  apoplectic 
paroxysm.”  (Bland  on  Human  and  Comparative  Parturition,  1794,  p.  138.)  “ When  a state 
of  coma  and  stertorous  breathing  prevails,  the  disease  assumes  the  semblance  of  apoplexy.” 
(Ramsbotham’s  Pract.  Obs.,  part  ii.  p.  247.) 


PUERPERAL  CONVULSIONS. 


401 


sive  action  of  the  muscles  than  the  coma  attendant  on  apoplexy ; and  this 
opinion  is  borne  out  by  our  observations  on  infants. 

In  infancy,  as  anatomical  investigations  demonstrate,  the  nervous  sys- 
tem bears  a very  large  proportion  to  the  general  bulk  of  the  body ; and  we 
may  presume  that  its  influence  on  the  body  generally  is  in  proportion  to  its 
development.  Now,  we  very  rarely  see  such  a disease  as  the  apoplexy  of 
adult  age  in  an  infant ; but  when  the  brain  is  irritated  by  pressure  or  other 
causes,  convulsive  paroxysms  are  excited.  I consider,  then,  the  case 
of  puerperal  convulsions  to  be  exactly  analagous  to  that  of  infantile  con- 
vulsions, and  that  they  are  both  of  them  allied  to  apoplexy ; the  causes, 
however,  acting  upon  the  system  under  a highly  excitable  state.  This 
view  of  the  case,  whether  correct  or  not,  is  practically  valuable,  and  will 
lead  to  the  most  judicious  treatment.  It  was  the  want  of  tracing  this  ana- 
logy between  puerperal  convulsions  and  apoplexy  that  introduced  the  de- 
structive practice  until  late  years  so  universally  adopted. 

Atmospheric  influence. — I have  remarked  that  puerperal  convulsions  are 
much  more  frequent  in  hot  weather  than  in  cold,  and  especially  at  times 
when  the  atmosphere  is  charged  with  electricity.  Thus,  they  are  oftener 
met  with  towards  the  end  of  summer  and  in  the  autumn,  or  in  the  spring, 
when  a few  unusually  warm  days  have  suddenly  burst  upon  us.  My 
father  many  years  since  called  my  attention  to  the  fact  of  convulsions 
being  more  frequent  when  (to  use  a common  expression)  there  was  “ thun- 
der in  the  air,”  than  at  any  other  time ; and  he  has  pointedly  mentioned 
such  a conviction  in  the  second  part  of  his  work.*  Andralf  has  more 
recently  stated  his  opinion  to  the  same  effect,  when  speaking  of  convulsions 
in  general.  “ The  electrical  state  of  the  air  on  the  approach  of  a storm 
has  often  served  to  bring  on  a convulsive  fit.”  And  DenmanJ  remarks, 
— “ It  has  been  justly  observed,  that  women  are  far  more  liable  to  puerpe- 
ral convulsions  in  certain  years  and  seasons  than  in  others  and  he  then 
proceeds  to  enumerate,  among  other  causes,  “ the  particular  influence  of 
the  air.”  Nor  did  this  circumstance  escape  the  acute  Smellie ; for  he  states, 
that  in  the  course  of  the  year  174?  he  attended  several  patients  who  were  at- 
tacked near  their  full  time  with  convulsions ; that  other  practitioners  also  saw 
similar  cases  during  the  same  time,  “ so  that  they  seem  to  have  proceeded 
from  the  constitution  of  the  weather.”§  Whether  this  liability,  indeed, 
merely  arises  from  women  not  being  able  to  bear  the  fatigue  of  labour  as 
well  in  hot  weather  as  in  cold,  or  from  the  blood  being  then  more  rarified 
— or  whether  it  be  that  such  kind  of  weather  exerts  some  specific  influence 
over  the  system,  particularly  of  puerperal  women,  which  predisposes  to 
these  convulsive  attacks, — I cannot  pretend  to  determine ; but  I suspect 

* Pract.  Obs.,  p.  248. 

t Introduction  to  Midwifery,  chap.  xvi.  sect.  2. 

51 


f Op.  et  loc.  cit. 

§ Mid.  1799,  vol.  ii.  p.  285. 


402 


COMPLEX  LABOURS. 


that  the  peculiar  effect  is  principally  to  be  attributed  to  the  atmosphere 
being  highly  charged  with  electric  fluid. 

Proximate  cause. — The  most  usual  proximate  cause  of  puerperal  con- 
vulsions is  probably  pressure  on  the  brain ; this  pressure  being  sometimes 
produced  by  the  rupture  of  a vessel,  causing  a sudden  effusion  of  blood ; 
sometimes  by  serous  exudation  into  the  ventricles,  or  between  the  mem- 
branes ; sometimes, — and  by  far  the  most  frequently, — by  simple  conges- 
tion of  the  cerebral  vessels  themselves.  But.  the  disease  has  often  proved 
fatal  without  any  organic  lesion  being  evident  on  dissection,  and  without 
even  the  vessels  being  observed  to  be  preternaturally  full.* * * §  In  this  respect, 
also,  there  appears  a strong  analogy  between  apoplexy  and  puerperal 
convulsions;  for  Zuliani,  of  Brescia,  in  1780  ;f  Kortum,  of  Dortmund,  in 
1785  ;J  and,  more  recently,  Abernethy,  among  us,  have  recognised  a 
species  of  apoplexy,  to  which  the  term  nervous  has  been  given.  In  two 
cases,  also,  related  by  Abercrombie, § of  his  simple  apoplexy , no  anormal 
appearance  was  observed  after  death. 

Remote  causes. — Into  the  remote  causes  it  is  not  my  wish  to  enter  at 
any  length,  because  the  subject  is  at  best  but  unsatisfactory,  and  little 
understood.  They  have  been  ascribed  to  articles  of  food  remaining 
undigested  on  the  stomach,  or  irritation  existing  in  some  other  part  of 
the  alimentary  tube ; — to  general  irritability  of  constitution; — to  a delicate 
and  luxurious  mode  of  living ; — to  the  depressing  passions ; — to  an  over- 
loaded state  of  the  system ; — to  over-distention  of  the  uterus ; — to  disten- 
tion of  the  bladder ; and  to  the  death  of  the  child.  But  the  affection,  in 
my  opinion,  originates  most  frequently  in  some  deranged  state  of  the  uterus 
itself,  probably  in  its  nervous  system,  and  consists  in  some  irritation  pro- 
pagated from  that  organ  to  the  brain. || 


* See  my  father’s  Pract.  Obs.,  part  ii.  p.  248. 

t F.  Zuliani  de  Apoplexia,  prsesertim  Nervea.  Lipsiae,  1780. 

\ Car.  G.  Theod,  Kortum  de  Apoplexia  Nervosa.  Gott.  1785  ; apud  Ludwig,  tom.  iv. 

§ Diseases  of  the  Brain  and  Spinal  Chord,  1828. 

II  I have  met  with  three  or  four  cases  which  have  strongly  impressed  me  with  the  idea 
advanced  in  the  text,  the  most  striking  of  which  is  the  following : — I was  called,  some  years 
ago,  by  one  of  the  midwives  of  the  Royal  Maternity  Charity,  to  the  assistance  of  a woman 
under  puerperal  convulsions.  When  I arrived  I found  she  had  been  bled  largely  by  a medi- 
cal friend  living  in  the  neighbourhood,  who  had  been  sent  for  on  the  instant  of  the  attack. 
The  bleeding  had  relieved  her  partially,  but  it  was  thought  right  to  repeat  it.  A third  quan- 
tity of  blood  was  taken  some  time  after,  with  such  a beneficial  effect  that  the  convulsions 
entirely  ceased,  and,  in  a few  hours,  perfect  consciousness  had  gradually  returned.  About 
fifty  hours  after  the  attack,  active  labour  came  on  ; and  in  less  than  five  hours  more  the  child 
was  born,  dead.  The  placenta  did  not  descend,  and  two  hours  subsequent  to  the  expulsion 
of  the  child  I was  summoned.  I found  her  perfectly  sensible,  in  good  spirits,  and  she  made 
no  complaint.  There  had  been  no  haemorrhage,  the  uterus  was  not  strongly  contracted,  and 
the  placenta  entirely  within  it.  Under  no  greater  anxiety  than  I usually  feel,  when  the 
placenta  is  retained,  I proceeded  in  the  ordinary  way  to  remove  it.  The  moment  I had 


\ 


puerperal  convulsions,  ( Symptoms . ) 403 

Symptoms. — The  symptoms  of  puerperal  convulsions  are  so  prominent 
and  strong,  that  if  once  the  disease  has  been  seen,  there  is  no  likelihood 
of  its  being  mistaken.  If  they  occur,  as  is  usually  the  case,  during  the 
first  stage  of  labour,  the  patient  is  probably  sitting  or  walking ; she  may 
be  even  occasionally  joining  in  conversation ; and,  without  giving  any 
previous  warning,  suddenly  falls  down  in  a strong  fit.  All  the  voluntary 
muscles  of  the  body  are  thrown  into  a state  of  violent  spasms,  alternating 
with  relaxation,  so  as  to  produce  rapid  and  powerful  contortions  and 
struggles  ; the  fore-arms  and  legs,  but  particularly  the  former,  are  jerked 
backwards  and  forwards  with  great  rapidity ; and  the  strength  of  two  or 
three  assistants  is  required  to  restrain  the  patient.  The  face  becomes 
turgid  and  livid,  swollen  by  the  increased  quantity  of  blood  with  which 
the  vessels  are  loaded.  The  throat  also  seems  to  swell,  the  carotids  beat 
inordinately,  and  the  jugular  veins  appear  prominent.  The  countenance 
assumes  a most  hideous  expression,  partly  from  the  suffused  state  of  the 

passed  my  hand  completely  into  the  uterine  cavity  the  patient  turned  upon  her  abdomen,  and, 
without  uttering  any  expression  of  pain,  went  into  a convulsion,  though  not  of  a violent  kind ; 
intense  coma  supervened,  which  yielded  to  no  treatment  I could  devise,  and  terminated  fatally 
in  about  two  hours  from  the  removal  of  the  placenta.  The  vagina,  and  especially  the  inner 
surface  of  the  uterus,  communicated  to  the  hand  a more  pungent  sense  of  heat  than  I recol- 
lect to  have  experienced  on  any  other  occasion. 

About  forty-eight  hours  after  her  death  I made  an  accurate  inspection  of  the  body.  The 
dura  mater  adhered  more  firmly  than  usual  to  the  inner  surface  of  the  cranium,  but  was 
healthy  in  appearance  ; the  vessels  of  the  brain  contained  less  blood  than  ordinary  ; the  plexus 
choroides  were  quite  blanched ; there  was  no  fluid  in  the  lateral  ventricles,  none  between  the 
membranes,  at  the  upper  part  of  the  skull,  but  about  two  drachms  at  the  base  of  the  brain ; 
no  extravasation  of  blood  existed  in  any  part  of  the  cerebral  mass.  The  viscera  were  all 
healthy  ; the  uterus  was  contracted  ; nor  did  it  present  any  uncornmou  appearance. 

Here  was  as  clear  a case  as  can  possibly  be  made  out  of  irritation  propagated  immediately 
from  the  uterus  to  the  brain;  and  I have  no  question  in  my  own  mind,  that  if  the  placenta 
had  not  unfortunately  been  adherent,  but  thrown  off  naturally,  the  woman  would  have  recovered 
perfectly. 

Ingleby  has  related  a case  almost  analogous  ; the  patient,  however,  not  having  suffered  any 
convulsion  before  delivery.  “ A highly  esteemed  friend  of  mine  once  found  it  necessary  to 
pass  his  hand  into  the  uterus  for  the  purpose  of  removing  an  adherent  placenta,  the  ergot  of 
rye  having  been  previously  administered.  The  introduction  was  carefully  performed.  The 
straining  and  opposition  to  his  efforts,  on  the  part  of  the  woman,  were  exceedingly  great;  and 
at  the  moment  when  the  operator’s  hand  had  reached  the  organ,  my  own  hand  making  coun- 
ter-pressure on  the  abdomen,  the  patient  became  violently  convulsed,  and  died  in  less  than  a 
minute.” — (On  Ut.  Haemor.,  p.  186.) 

The  cause  of  this  convulsion  could  not  have  been  excessive  loss  of  blood,  because  Ingleby 
would  doubtless  have  mentioned  that  fact,  if  it  had  been  so ; besides,  if  the  woman  had  been 
faint  from  haemorrhage,  she  could  not  have  so  strongly  resisted  the  efforts  made  to  introduce 
the  hand.  He,  indeed,  expressly  gives  his  opinion  from  the  state  of  the  pulse  that  she  died 
from  apoplexy.  I look  upon  this  case  as  one  also  proving  that  the  remote  cause  of  this  kind 
of  convulsion  often  exists  in  the  uterus,  and  that  the  irritation  is  propagated  through  the 
agency  of  the  nervous  system  to  the  brain. 


404 


COMPLEX  LABOURS. 


features,  and  partly  from  their  distortion  and  convulsive  action.  The 
eyes  seem  starting  from  their  sockets ; and,  in  consequence  of  the  spasmo- 
dic action  of  their  muscles,  are  drawn  obliquely  upwards,  one  to  the  inner 
and  the  other  to  the  outer  canthus ; so  that  none  of  the  pupil,  and  but  a 
small  portion  of  the  cornea,  can  be  seen.  The  eye-lids  are  half  open,  and 
violently  agitated;  the  pupils  themselves  (if  the  eyes  can  be  so  opened  as 
to  obtain  a sight  of  them)  are  generally  dilated;  sometimes,  however, 
more  than  usually  contracted;  (or  one  is  preternaturally  contracted, 
while  the  other  is  widely  dilated  ;)  and  I have  then  observed  them  expand, 
in  the  interval  of  the  fits,  on  the  application  of  light.  The  lips  partake  of 
the  general  convulsion.  The  angle  of  the  mouth  is  drawn  upwards  to 
one  or  other  side,  and  twitched  spasmodically.  At  the  commencement 
of  the  fit  the  lower  jaw  is  depressed  and  drawn  considerably  to  one  side; 
but  the  temporal  and  masseter  muscles  soon  act  with  amazing  strength, 
and  firmly  clench  the  teeth  together.  The  tongue  is  almost  invariably 
protruded  beyond  the  gums ; and  the  muscles  of  the  jaw  contracting 
powerfully  at  the  same  time,  catch  it  between  the  teeth,  and  lacerate  it 
dreadfully.  A quantity  of  frothy  saliva  escapes  from  the  mouth,  generally 
tinged  with  blood,  which  issues  from  the  wounded  tongue,  adding  very 
much  to  the  hideousness  of  the  aspect.  The  breathing  is  deep,  irregular, 
and  laboured,  and  performed  with  a sharp  hissing  noise,  from  the  air  being 
impeded  in  its  passage,  partly  by  the  clenched  teeth,  and  partly  by  the 
saliva,  which  hangs  about  the  lips.  The  pulse,  during  the  paroxysm, 
varies,  being  full,  slow,  and  oppressed,  at  the  commencement  and  before 
the  attack,  and  increasing  in  velocity  as  the  intensity  of  the  fit  becomes 
greater.  As  these  frightful  and  alarming  symptoms  occur  so  suddenly,  it 
is  not  surprising  that  they  should  strike  the  attendants  with  terror  and 
dismay.  So  general  and  powerful  is  the  alarm,  that  every  one,  in  the 
distress  of  the  moment,  is  running  in  search  of  they  know  not  what ; and 
the  medical  attendant,  deprived  of  the  assistance  of  the  bystanders,  is 
often  compelled  to  collect  for  himself  whatever  he  may  require. 

After  an  uncertain  time,  the  violence  of  the  fit  abates ; and  probably  in 
a few  minutes  the  convulsion  will  have  quite  disappeared.  The  patient 
then  will,  perhaps,  slowly  recover  her  consciousness ; she  appears  as  if 
she  were  awaking  from  sleep,  is  perfectly  unaware  that  any  thing  dan- 
gerous or  extraordinary  has  happened,  and  has  no  recollection  whatever 
of  the  interval.  She  will  most  likely  complain  now  of  an  agonizing  pain 
in  the  head.  This  truce  will  quiet  the  attendants,  and  restore  something 
like  tranquillity  in  the  lying-in-room.  Short-lived,  however,  are  their 
favourable  expectations:  another  attack  will  presently  dissipate  their 
hopes,  and  again  all  are  thrown  into  confusion. 

At  other  times,  and  more  frequently,  although  the  more  violent  symp? 


puerperal  convulsions,  ( Symptoms .)  405 

toms  of  the  attack  have  subsided,  the  patient  remains  comatose,  without 
feeling  or  motion,  lying  in  the  senseless  state  of  apoplectic  stupor ; the 
breathing  heavy,  dull,  and  stertorous.  At  others,  again,  a certain  degree 
of  consciousness  returns,  a knowledge  of  persons  and  objects,  but  an  ina- 
bility to  articulate  or  make  the  wishes  known ; and  often,  with  a partial 
return  of  consciousness,  there  is  a constant  rolling  about  the  bed,  and  a 
low  and  distressing  moaning.  During  the  continuance  of  the  fits,  uterine 
action  is  not  suspended,  although  no  signs  of  pain  are  manifested  by  the 
woman,  if  she  remain  comatose.  Sometimes,  with  each  return  of  ute- 
rine action,  a fresh  paroxysm  occurs ; so  that  we  may  count  the  frequency 
and  duration  of  the  pains  by  the  number  and  length  of  the  fits.  Occa- 
sionally, under  convulsions,  dilatation  and  expulsion  have  gone  on  so 
rapidly,  that  the  child  has  been  propelled  into  the  world  before  the  attend- 
ants were  aware  that  labour  had  begun ; and  many  instances  have  come 
under  my  own  eye  of  a child  being  expelled  during  a strong  fit.  Baude- 
locque  states,  that  he  has  seen  some  cases  in  which  he  found  the  child 
between  the  woman’s  thighs,  though  “ an  instant  before  he  could  discover 
no  disposition  for  delivery.”*  Thus  convulsions  neither  suspend  nor  inter- 
fere with  efficient  uterine  action. 

The  infant  is  generally,  though  by  no  means  universally,  born  dead, 
when  the  woman  has  been  the  subject  of  convulsive  seizures,  especially  if 
the  attack  has  occurred  early  in  the  labour,  and  continued  for  any  length 
of  time.  It  is  difficult  to  account  for  this  circumstance : pressure  on  the 
child’s  body  or  the  funis  umbilicalis,  alone,  cannot  explain  it.  I suspect 
it  is  owing  to  the  necessary  changes  in  the  foetal  blood  not  being  effected 
during  its  circulation  through  the  placenta,  or  to  some  baneful  influence 
propagated  to  it  from  its  parent.  Denmanj*  justly  remarks,  that  the  death 
of  the  child  is  rather  to  be  considered  as  a consequence  than  as  a cause 
of  the  convulsions ; and  Spence  gives  a case  in  which  the  mother  having 
died  of  convulsions  before  there  was  any  disposition  to  labour,  the  Caesa- 
rean section  was  performed  immediately  after : the  child  was  extracted 
alive,  was  itself  soon  seized  with  convulsive  paroxysms,  and  died  in  less 
than  hour.J 


* Translation,  parag.  1109.  This  must  surely  be  an  exaggeration ; but  I have  known  no 
few  instances  where  the  persons  in  attendance  would  not  believe  that  the  child  was  born,  be- 
cause they  had  no  idea  that  labour  was  instituted, 
t Chap.  xvi.  sect.  2.  ^ 

t System  of  Mid.,  Appendix,  case  47. 

If  the  paroxysms  do  not  come  on  till  after  the  termination  of  the  labour,  the  child  is  almost 
always  living ; and  in  proportion  to  the  number  of  fits,  the  length  of  time  the  disease  has 
lasted  before  delivery,  and  the  general  violence  of  the  attack,  will  be  the  probability  of  the 
infant  being  born  dead.  M.  Menard  thinks  the  child’s  death  is  owing  to  its  having  suffered 


406 


COMPLEX  LABOURS. 


Premonitory  symptoms. — Convulsions  often  arise  suddenly,  as  just  de- 
scribed, without  any  premonitory  symptoms : sometimes,  however,  and  I 
think  almost  generally,  there  are  signs  which  appear  a few  days  previously 
to  the  convulsions  showing  themselves ; and  at  other  times  there  are  some 
which  immediately  precede  the  fit  itself.  Thus  a woman  will  perhaps 
seem  perfectly  well,  bearing  the  commencing  pains  of  labour  with  great 
fortitude,  and  in  good  spirits,  when  she  begins  to  ramble  in  her  mind,  talks 
incoherently,  and  will  perhaps  suddenly  declare  that  there  is  a bright  light 
in  the  room ; and  a convulsive  paroxysm  immediately  succeeds.  In  my 
father’s  176th  case,  the  attack  was  ushered  in  with  the  exclamation  that 
the  room  was  studded  with  diamonds.  After  such  a declaration,  then, 
we  might  expect  an  attack  of  this  frightful  disease ; but  little  time  would 
be  granted  us  for  acting  in  prevention,  since  the  more  violent  symptoms 
would  almost  instantly  follow. 

But  there  are  others  which  appear  a few  days  or  hours  before  the  fit, 
leading  us  to  suspect  that  convulsions  are  likely  to  occur;  but  yet  not  so 
strongly  marked  as  to  warrant  us  in  saying  that  the  patient  must  neces- 
sarily experience  an  attack.  These  are  such  as  we  are  in  the  habit  of 
referring  to  an  overloaded  state  of  the  brain ; — intense  headach ; a feeling 
as  if  a blow  was  inflicted  on  the  head ; giddiness ; a sensation  of  intoxica- 
tion, and  inability  to  walk  straight ; drowsiness ; singing  in  the  ears,  and 
deafness ; total  or  partial  loss  of  sight ; scintillse,  or  muscce  volitantes , float- 
ing before  the  eyes  in  rapid  succession ; impeded  utterance ; numbness  or 
cramps  in  the  arms,  and  occasionally  severe  cramps  in  the  stomach. 
Such  symptoms,  especially  in  full  habits,  should  never  be  neglected : 
we  may  infer  that  they  arise  from  a fulness  of  the  vessels  of  the  brain, 
and  in  most  instances  may  deplete  the  patient  both  by  bleeding  and 
purging. 

Prognosis. — Our  prognosis  must  be  most  guarded  in  all  cases  of  puer- 
peral convulsions ; for  it  is  a highly  dangerous  affection ; and  the  danger 
is  in  proportion  to  the  length  and  strength  of  the  fit ; the  shortness  of  the 
interval ; but  more  especially  to  the  degree  of  consciousness  between  the 
paroxysms.  If  the  patient  lies  in  a state  of  complete  stupor,  accompanied 
with  stertorous  breathing,  when  the  paroxysm  has  subsided,  and  insensi- 
ble to  any  ordinary  stimulus  that  could  be  applied,  even  though  the  fits 
might  be  of  short  duration,  I should  consider  her  in  greater  danger  than 
if  the  convulsions  were  stronger,  with  a state  of  perfect  consciousness  in 
the  intervals  of  the  attacks.  Usually,  the  stronger  the  fits  the  deeper  is 


convulsions  before  delivery,  and  states  that  the  contraction  of  its  features  and  limbs  on  its  birth 
proves  this  to  be  the  case.  (See  Diet,  of  Pract.  Med.,  Art.  Convulsions.)  I have  not  observed 
such  an  appearance  of  the  infant  in  any  case. 


puerperal  convulsions,  ( Treatment .)  407 

the  accompanying  coma ; but  that  is  not  always  the  case ; and  I would 
rather  form  my  prognosis  by  the  intervening  state  than  by  the  actual  vio- 
lence of  the  fits  themselves.  We  may  comfort  ourselves  with  the  assurance, 
however,  that, — although  convulsions  are  so  dangerous,  and  although  our 
prognosis  must  be  in  the  highest  degree  guarded, — under  our  present  im- 
proved treatment,  the  danger  is  scarcely  in  proportion  to  the  frightfulness 
of  the  patient’s  appearance  and  the  excessive  alarm  occasioned.  The 
terror  created  in  the  minds  of  the  friends  is  often  so  great  that  they  at 
once  give  up  the  case  as  hopeless ; and  conceive  the  patient  must  be  dying. 
In  this  respect,  convulsions  and  haemorrhages  are  strongly  contrasted  with 
each  other ; in  the  latter  case,  it  not  unfrequently  happens  that  the  fatal 
event  is  stealing  on  so  insensibly,  that  the  anxious  friends,  who  are  watch- 
ing by  the  bed-side,  are  not  aware  of  the  impending  danger  until  there  is 
but  little  chance  of  recovery  left.  If  we  could  be  certain,  indeed,  that  no 
permanent  injury  had  been  inflicted  on  any  part  of  the  nervous  system,  I 
think  we  might  with  much  confidence  hope  for  a favourable  issue  of  most 
cases  of  puerperal  convulsions.* 

Treatment. — Our  first  duty,  on  the  accession  of  a fit,  should  be  to  pro- 
tect the  patient  from  injuring  herself  by  the  violence  of  her  struggles ; and 
then  to  endeavour  to  prevent  a recurrence  of  the  paroxysms.  With  the 
first  intention,  one  or  two  strong  assistants  should  restrain  her,  so  as  to 
preclude  the  possibility  of  her  throwing  herself  off  the  bed,  and  striking 
her  head  or  arms  against  any  hard  body.  Advantage  must  be  taken  of 
the  depression  of  the  lower  jaw,  which  occurs  at  the  commencement  of 
each  convulsive  paroxysm,  to  insert  some  hard  substance  between  the 
molar  teeth,  with  a view  to  protect  the  tongue.  A piece  of  fire-wood, — 
which  can  generally  be  procured  on  the  instant, — will  answer  the  purpose 
perfectly  ^ell : it  should  be  wrapped  round  with  a handkerchief  or  small 
fold  of  linen,  and  kept  steadily  in  its  place  by  an  assistant,  till  the  end  of 
the  fit:  if  allowed  to  slip  out  for  a moment,  the  jaws  may  be  violently 
closed,  and  extensive  injury  sustained.  I have  many  times  known  the 
tongue  so  swollen  by  inflammation,  consequent  on  laceration,  that  the 
teeth  could  not  be  brought  together  for  some  days. 

Means  must  next  be  taken  to  relieve  the  patient  effectually.  Believing 
that  the  cause  most  commonly  consists  in  pressure  to  which  the  cerebral 
mass  is  subjected,  the  same  treatment  must  be  adopted  that  we  would 
have  recourse  to  under  ordinary  apoplexy,  viz.,  the  abstraction  of  blood, 
and  acting  briskly  on  the  intestinal  canal.  Bleeding  is  our  great  reliance 


* From  what  I have  seen  of  this  disease,  I should  say  that  convulsions  coming  on  after 
delivery,  if  the  patient  has  not  suffered  an  attack  before,  arc  not  so  dangerous  as  those  which 
arise  during  pregnancy  and  labour. 


-—the  lancet  is  our  sheet-anchor — and  blood  may  be  taken  to  a very  large 
extent;  it  may  be  necessary  to  draw  forty,  fifty,  or  sixty  ounces,  nay, 
even  more,  in  the  course  of  a very  few  hours.  If  ten  or  twelve  only  be 
abstracted,  the  patient  seldom  obtains  much  benefit ; depletion  will  avail 
us  little,  unless  a decided  impression  be  made  on  the  system  generally. 
We  observe  that  a woman  will  bear  the  loss  of  a larger  quantity  of  blood 
under  puerperal  convulsions, — as  in  apoplexy — without  fainting,  than 
in  almost  any  other  affection.  Venesection,  however,  had  better  not 
be  attempted  during  the  paroxysm ; for  the  struggles  of  the  patient  will 
most  likely  prevent  its  being  properly  and  beneficially  performed.  We 
may  content  ourselves  with  guarding  her  as  perfectly  as  we  can  until 
the  fit  subsides ; and  when  it  has  passed  over,  and  she  lies  in  a state  of 
coma,  or  sensibility  is  somewhat  returning,  the  operation  will  be  easy. 

Her  head  and  shoulders  should  be  raised  as  high  as  conveniently  may 
be,  a free  opening  made  in  one  or  both  arms,  and  the  blood  allowed  to 
run  in  a full  stream.  At  first  it  will  probably  flow  sluggishly,  and  dark  in 
colour;  afterwards  it  will  come  more  freely,  and  of  a more  natural  appear- 
ance ; and  it  should  not  be  restrained  until  a sensible  effect  be  made  upon 
the  pulse;  or  commencing  pallor  of  the  lips  indicate  approaching  faintness. 
The  probability  is,  that  from  twenty  to  thirty  ounces  will  be  abstracted 
before  this  effect  is  produced.  The  quantity,  within  a certain  moderation, 
should  not  be  regarded;  graduated  vessels  in  such  a case,  to  measure  the 
loss  by,  are  not  required,  any  thing  nearest  at  hand  will  serve  our  pur- 
pose equally  well. 

Our  next  indication  is  to  procure  copious  evacuations  from  the  bowels 
as  early  as  possible.  If  the  woman  be  sensible  there  will  be  no  difficulty 
in  administering  medicine  for  this  object  by  the  mouth;  but  if  she  remain; 
still  under  coma,  she  may  perhaps  be  unable  to  swallow.  An  attempt 
may,  nevertheless,  be  made  to  get  some  cathartic  into  the  stomach;  and' 
with  this  view,  ten  or  twelve  grains  of  calomel  may  be  mixed  with  a little 
sugar  and  put  upon  the  tongue ; and  a table-spoonful  of  infusion  of  senna 
and  jalap  may  be  exhibited  every  half  hour,  till  stools  are  produced.  The 
probability  is,  that  some  part  will  pass  down : for,  in  most  instances,  if 
we  watch  the  proper  opportunity,  deglutition  may  be  accomplished.  In 
case,  however,  this  cannot  be  effected,  a strong  purgative  enema  may  be 
injected,  and  repeated  if  necessary ; or  a drop  or  two  of  croton  oil  diffused 
in  a few  grains  of  any  suitable  powder*  may  be  thrown  into  the  mouth, 
and  a second  dose  administered,  should  the.  first  not  act  within  a reason- 
able interval  ^ or  both  tfiese  means  may  be  used  in  combination.  Tur- 
pentine or  assafoetida  may  be  injected  into  the  bowels,  occasionally  with 
great  advantage. 

By  some,  emetics  have  ,beenf recommended ; but  unless  there  were  indi- 


puerperal  convulsions,  ( Treatment. ) 409 

cations  of  the  stomach  containing  undigested  food  in  considerable  quantity, 
I think  emetics  not  called  for ; and  commonly  purgatives  will  answer  the 
purpose  of  relieving  the  alimentary  canal  better  than  emetics.*  Though 
the  symptoms  may  give  way  for  a time,  we  are  not  to  expect  an  imme- 
diate cessation  of  the  fits ; a fresh  attack  will  most  likely  occur,  mode- 
rated or  not  in  intensity,  according  to  circumstances : after  the  lapse  of  a 
short  period,  therefore,  another  bleeding  may  be  required ; nor  should  w7e 
hesitate  to  have  recourse  to  the  lancet  a second  or  even  a third  time,  if 
the  arterial  system  regain  its  power. 

As  an  auxiliary  of  no  mean  consideration,  the  hair  may  be  taken  off, 
and  cold  applied  to  the  scalp,  and  the  shoulders  should  be  kept  in  an  ele- 
vated position.  Gooch, f Blundell, J and  Copland, § speak  of  the  advantage 
sometimes  to  be  derived  from  drawing  the  woman’s  person  partly  over 
the  edge  of  the  bed,  and  pouring  water  unsparingly  on  the  head. 

I think  it  useless,  while  the  violence  of  the  convulsions  lasts,  to  attempt 
the  application  of  cupping-glasses  to  the  back  of  the  neck  or  behind  the 
ears,  or  even  leeches  to  the  temples ; or  to  blister  the  shaved  head,  or  nape 
of  the  neck.  The  contortions  of  the  patient’s  body  would  prevent  the 
glasses  being  fixed,  and  there  would  be  a great  chance  of  their  being  bro- 
ken, even  if  properly  adjusted.  It  would  perhaps  be  less  difficult  to  apply 
leeches,  but  they  are  too  slow  in  acting  for  our  present  purpose,  and  the 
urgency  of  the  case  demands  more  prompt  and  effectual  means.  The  same 
disadvantages  attach  to  blisters,  even  in  an  increased  degree.  Not  that 
I object  to  local  depletion ; it  is  certainly  desirable  to  unload  the  vessels 
of  the  brain  by  any  method  in  our  possession ; but  general  bleeding  is  far 
preferable  to  the  less  powerful  resources.  Provided,  then,  the  symptoms 
are  but  little  alleviated, — while  delivery  is  impossible,  or  would  be  attended 
with  much  hazard, — we  may  open  the  temporal  artery,  or  the  jugular 
vein ; and  thus  secure  the  advantages  both  of  general  and  local  depletion 
at  the  same  time.|| 

But  we  may  be  fearful  of  taking  any  more  blood  either  from  the  arm 
or  nearer  to  the  seat  of  distress,  while  yet  the  convulsive  fits  continue  una- 
bated in  their  severity : under  such  a case  we  have  only  one  other  re- 
source— delivery,  if  it  can  be  effected.  Emptying  the  uterus  will  usually 
put  a stop  to  the  fits,  at  any  rate  for  a time;  and  if  there  be  no  permanent 

* Were  I summoned  to  a patient  soon  after  she  had  made  a hearty  meal,  and  especially  if 
■she  had  eaten  freely  of  shell  fish  or  other  not  easily  digestible  food,  I should  exhibit  a brisk 
emetic  before  resorting  to  purgatives* **  . * 

t Compendr,  p.  247.  # t Obsletricy,  b^  Castle,  p.  648. 

§ Diet,  of  Pract,  Med.,  Art.  Convulsions,  p.  434. 

||  “ When  from  circumstances  it  is  difficult  to  procure  a sufficient  supply  from  the  arm,  the 
temporal  artery  may  be  opened,  or  cupping-glasses  applied  behind  the  ears  or  on  the  temples.” — 
(Locock,  Cyclop,  of  Pract.  Med,,  Art.  Puerperal  convulsion?.)  . 

52 


410 


COMPLEX  LABOURS. 


injury  done  to  the  brain,  it  will  generally  mitigate  them  most  materially. 
According  to  the  progress  the  labour  has  made,  must  be  the  means  we 
employ  for  this  object.  Thus,  if  the  foetal  head  be  low  down  in  the  pelvis 
so  that  we  can  feel  an  ear,  we  may  have  recourse  to  the  short  forceps ; 
if  it  be  not  within  their  scope,  the  long  forceps  may  be  employed  ; and  if  it 
remain  entirely  above  the  brim,  we  may  be  driven  to  the  use  of  the  per- 
forator. Again ; should  the  membranes  be  unbroken,  we  may  turn  the 
child  and  deliver  by  the  feet.  Of  all  these  methods,  we  should  much  pre- 
fer delivery  by  the  forceps,  if  it  could  be  effected  without  injury ; but,  un- 
fortunately, the  operation  is  rendered  very  difficult,  and  in  no  small  degree 
hazardous,  by  the  rapid  contortions  accompanying  each  fit,  and  the  inces- 
sant movements  of  the  person  in  the  interval  of  the  paroxysms ; which 
condition  is  mostly  present  when  delivery  is  required.  Although,  then, 
the  alternative  offered  by  craniotomy  is  painful  to  contemplate,  we  should 
resort  to  it  rather  than  run  the  risk  of  inflicting  extensive  injury  on  the 
mother’s  person.  The  child  indeed,  as  I have  before  stated,  is  very  fre- 
quently born  still,  after  the  mother  has  suffered  from  convulsions ; but  the 
chance  of  its  previous  death  would  not  warrant  us  in  taking  the  perforator 
in  hand,  if  delivery  could  be  accomplished  safely  in  any  other  manner. 

Neither  is  the  operation  of  turning  under  convulsions  free  from  objec- 
tions. It  would  be  most  unwise  to  attempt  its  performance  if  the  head 
were  engaged  in  the  brim  of  the  pelvis — if  the  membranes  had  been  rup- 
tured for  any  length  of  time,  and  the  uterus  were  strongly  contracted 
round  the  child’s  body ; because  of  the  difficulty  we  must  encounter,  and 
the  danger  we  must  necessarily  incur.  Nor  would  it  be  judicious  to  at- 
tempt the  forcible  dilatation  of  the  os  uteri  by  the  hand,  especially  if  it  be 
rigid.  Bearing  in  mind  that  the  remote  cause  probably  exists  in  the 
uterus,  and  that  the  fits  may  owe  their  origin  to  irritation  propagated  from 
that  organ  to  the  brain,  we  should  be  most  cautious  not  to  add  another 
source  of  irritation  by  our  manual  efforts.  Under  such  a state  of  things 
bleeding  should  be  carried  to  its  fullest  extent,  rather  than  delivery  be 
attempted.  If,  indeed,  the  mouth  of  the  womb  be  open  and  flaccid,  offer- 
ing little  or  no  resistance  to  the  passage  of  the  hand,  particularly  if  the 
woman  have  had  children  before,  and  if  the  membranes  be  still  entire  at 
a time  when  it  is  thought  requisite  to  evacuate  the  uterus, — turning  might 
be  undertaken  with  every  prospect  of  a happy  termination. 

Even  emptying  the  uterus,  however,  does  not  always  put  a stop  to  the 
fits ; though  they  generally  become  less  violent  when  the  labour  is  per- 
fected. If  they  continue  equally  as  strong  after  the  birth  as  before,  whe- 
ther the  delivery  has  been  natural  or  artificial,  I should  then  suspect  that 
some  lesion  had  taken  place  within  the  brain,  and  should  look  upon  the 
case  as  dangerous  in  the  extreme.  Still  a continuance  of  the  same  means 
may  be  used,  in  a modified  degree ; leeches,  cupping,  (if  it  can  be  accom- 


puerperal  convulsions,  ( Treatment.)  411 

plished,)  and  blisters,  may  now  be  had  recourse  to,  and  mustard  cata- 
plasms to  the  feet  or  calves  of  the  legs,  in  conjunction  with  cold  applica- 
tions to  the  head,  and  a continuance  of  purgative  medicines  by  the  mouth, 
and  turpentine  or  asafcetida  in  enema.  The  same  plan,  aided  by  perfect 
quietude,  a darkened  apartment,  elevated  position  of  the  upper  part  of  the 
trunk,  and  the  sparest  diet  consistent  with  the  due  performance  of  the 
various  functions  of  the  body,  will  also  be  found  efficacious  in  removing 
the  distressing  headach  which  often  remains  for  some  days  after  a con- 
vulsive seizure ; but  which  gradually  disappears  under  such  treatment. 
When  recovery  takes  place  it  is  mostly  perfect,  gradually  brought  about, 
and  no  trace  remains  of  the  serious  attack  the  patient  has  suffered. 

Merriman,*  indeed,  mentions  having  “known  two  or  three  instances  of 
mania  occurring  as  soon  as  the  convulsions  ceased,  and  remaining  for 
some  weeks,  yet  the  patients  ultimately  got  well and  another  of  true 
chronic  epilepsy,  which  continued  for  some  years,  until  the  woman  died 
of  pulmonary  disease.  Chronic  epilepsy  has  not  happened  as  a sequela  of 
puerperal  convulsions  under  my  own  observation ; nor  have  I ever  seen 
paralysis  of  any  of  the  limbs  follow;!  hut  I have  known  one  instance  in 
which  the  fits  appeared  in  three  successive  pregnancies,  and  two  where 
temporary  mania  supervened.  DeweesJ  mentions  a case  where  the  third 
and  fifth  labours  were  attended  with  convulsions,  as  well  as  the  first ; and 
he  attributes  the  return  to  neglect  of  proper  management  during  the  last 
weeks  of  pregnancy.  Both  Perfect§  and  Portal, ||  also,  as  well  as  Baude- 
locquell  and  Capuron,**  have  put  instances  on  record,  of  convulsions 
attacking  the  same  patient  in  subsequent  labours. 

The  contrast  between  the  fatality  of  the  cases  now  met  with,  and  those 
put  on  record  by  Saviard,  Portal,  and  others  in  the  seventeenth  century, 
and  Smellie,  Perfect,  and  Spence,  in  the  last,  cannot  but  be  a subject  of 
high  gratulation  to  the  practitioners  of  the  present  day.  Hunter,  Lowder, 
and  other  teachers,  were  accustomed  to  state  in  their  lectures, ff  that 
more  than  one-half  the  patients  attacked  with  this  disease  died.  Jacobsjf 
tells  us  that  the  case  is  almost  always  fatal,  scarcely  any  of  the  patients 
having  recovered ; and  in  Nisbet’s  “ Clinical  Guide  ”§§  we  read,  that  when 

* Synopsis,  p.  140. 

t Lamotte  (Trait6  des  Accouch.,  edit.  1745,  Obs.  363)  notes  one  case  of  convulsions  in 
which  paralysis  occurring  before  delivery  continued  more  or  less  for  six  months;  but  he  ap- 
pends to  the  case  the  remark,  that  “this  very  attack  of  paralysis  proves  the  disease  to  have 
"been,  not  puerperal  convulsions,  but  apoplexy ; because  paralysis  is  not  a sequela  of  puerperal 
convulsions.” 

X System  of  Mid.,  502.  § Cases  in  Mid.,  case  158. 

||  Pract.  Obs.,  xvii.  ^ Parag.  1100,  trans. 

**  L’Art  des  Accouch.,  p.  397.  ft  Merriman,  Synops.,  p.  132. 

tt  Ecole  Pratique  des  Accouch.,  1785,  p.  238.  §§  1800,  p.  357. 


412 


COMPLEX  LABOURS. 


coma  accompanies  the  fits,  the  disease  “ generally,  though  not  always, 
proves  fatal.” 

Few,  comparatively,  under  good  care,  now  terminate  unfortunately;  and 
the  favourable  results  are  to  be  attributed  to  the  extent  to  which  bleeding 
and  other  evacuant  means  are  carried.  Gooch*  used  to  say  that  he  never 
had  lost  a patient  under  convulsions,  when  free  bleeding  had  been  prac- 
tised ; but  that  all  the  women  who  had  died  under  hjs  observation  had 
been  bled  insufficiently.  Eight,  ten,  or  twelve  ounces  of  blood  used  to 
be  considered  as  much  as  it  was  safe  to  abstract ; and  the  principal 
reliance  was  placed  on  antispasmodic  and  nervous  remedies,  as  they 
were  called,  consisting  principally  of  sether,  ammonia,  camphor,  musk, 
castor,  and  opium.  Such  medicines,  as  being  stimuli,  must  add  to  the 
danger,  by  increasing  the  power  of  the  circulating  organs,  and  throwing 
more  blood  on  the  already  overloaded  brain. 

There  has  been  much  disagreement  among  medical  men  as  to  the  value 
of  opium  in  puerperal  convulsions.  Manning, j*  Bland, J and  particularly 
Collins, § (who  combines  it  with  calomel  or  antimony,)  strongly  recom- 
mend it;  while  Hamilton,]]  Merriman,H  Burns,**  Dewees, ff  my  father, JJ 
with,  I think,  most  other  practitioners  of  the  present  day,  consider  it  inju- 
rious. My  own  observation  would  lead  me  strongly  to  condemn  it  while 
the  symptoms  are  urgent ; and  to  be  most  cautious  in  its  administration — 
if  I used  it  at  all — even  after  delivery,  or  when  the  violence  of  the  attack 
had  abated.  Hamilton§§  advocates  the  exhibition  of  camphor  in  large 
doses;  but,  for  myself,  I have  seen  not  the  least  advantage  from  this  drug 
during  the  continuance  of  the  convulsive  paroxysms. 

The  English  physicians  have  only  recently  in  comparison  carried  the 
depleting  practice  to  the  extent  now  almost  universally  adopted ; but  some 
of  the  earlier  French  authors  were  strong  advocates  for  the  advantage  of 
large  bleedings,  and  Puzos||||  particularly  insists  on  their  necessity.  Highly 
valuable,  however,  as  the  lancet  is  under  such  a state,  it  may  still  be 
abused : rashness  must  be  deprecated  here  as  well  as  in  other  diseases ; 
and  no  more  blood  should  be  taken  than  is  sufficient  to  produce  the  effect 
desired,  whatever  that  quantity  may  be.lHT 

* Op.  Cit.,  p.  244.  t On  Female  Diseases,  1771,  p.  388. 

X On  Human  and  Comparative  Parturition,  1794,  p.  139. 

§ Practical  Treatise  on  Mid.,  p,  227,  note,  ||  Pract.  Obs.,  p.  372. 

IT  Synopsis,  p.  135.  **  Principles  of  Mid.,  5th  edit.,  p.  469. 

+t  System  of  Mid.,  1825,  p.  510.  XX  Pract.  Obs.,  vol.  ii.  p.  271. 

§§  Pract.  Obs.  page  371. 

IIH  Traite  des  Accouch.,  chap.  xvi.  art.  2. 

IT  IT  The  accidental  loosening  of  the  bandage  tied  round  the  arm  after  venesection,  seem9  to 


PUERPERAL  CONVULSIONS,  413 

We  should  be  prepared  to  expect  that  a patient,  after  having  suffered  a 
convulsive  seizure,  would  have  no  remembrance  of  any  thing  that  occurred 
between  the  commencement  of  the  attack  and  the  time  that  she  regained 
her  sensibility ; and  we  not  only  find  this  to  be  the  case,  but  the  disease 
seems  frequently  to  wipe  away  all  recollection  of  events  that  had  hap- 
pened some  time  before  the  accession  of  the  fits,  while  she  was  perfectly 
conscious.  Thus  I have  known  many  instances  of  a woman,  apparently 
well  when  delivered,  who  (having  become  the  subject  of  convulsions  a few 
hours  after)  had  no  recollection  of  her  labour,  and  was  only  convinced 
that  she  was  delivered  by  her  child  being  brought  to  her.  My  father* 
mentions  a case  in  which,  “although  the  lady  at  the  time  of  her  delivery 
appeared  in  perfect  health,  she  had  no  recollection  whatever,  after  her  re- 
covery, of  the  occurrences  during  her  labour,  or  indeed  of  those  of  some 
days  preceding  that  event:  they  appeared  a blank  in  her  existence.,, 
Blindness  and  deafness,  continuing  for  some  days,  are  no  uncommon  con- 
sequences of  convulsions.  Denmanf  mentions  that  in  almost  every  case 
which  he  had  seen,  there  was  evidently,  after  delivery,  a greater  or  less 
degree  of  abdominal  inflammation ; Collinsf  has  found  a strong  tendency 

have  given  the  first  idea  of  the  value  of  larger  bleedings  than  it  was  formerly  the  practice  to 
resort  to.  This  case  occurred  to  Dr.  Bromfield;  and  is  mentioned  by  Denman,  chap,  xvi, 
sect.  5. 

* Practical  Obs„  part  ii.  case  183. 

The  last  patient  I attended  under  convulsions,  on  Tuesday,  December  8th,  1840,  when  she 
was  restored  to  consciousness,  had  lost  all  recollection  of  every  thing  that  had  happened  since 
the  previous  Wednesday.  Her  sister  came  from  the  country  to  spend  a few  days  with  her  on 
the  Saturday  before.  She  was  then  apparently  in  her  usual  health  and  spirits ; she  welcomed 
her  with  pleasure,  and  yet  she  has  now  not  the  least  remembrance  of  her  arrival.  On  the 
Monday  before  her  attack  she  had  visited  another  sister,  a patient  in  St.  Thomas’s  Hospital ; 
in  the  evening  had  walked  from  the  neighbourhood  of  Bishopsgate  Church  to  Temple  Bar 
with  her  husband  and  sister  ; and  after  her  return  called  on  a medical  man,  whom  she  had 
never  seen  before,  to  engage  his  attendance  in  her  expected  confinement.  She  remembers 
nothing  of  the  visit  to  the  hospital,  nor  the  subsequent  walk,  nor  of  seeing  this  gentleman; 
which  latter  circumstance,  as  he  was  a stranger,  might  be  supposed  to  have  made  an  impres- 
sion, She  is  equally  unconscious  of  all  that  passed  during  the  six  days.  She  recovered  her 
sensibility  on  Tuesday  evening ; having  been  in  a state  of  convulsions  alternating  with  coma 
for  about  sixteen  hours.  She  went  into  labour  on  the  following  Sunday  morning,  and  was  de- 
livered naturally.  It  was  her  first  pregnancy,  and  she  was  about  seven  months  advanced ; the 
child  was  born  dead.  She  has  recovered  perfectly, 

- In  vol.  iii.  of  the  Royale  Academie  de  Medecine,  there  is  a case  given  by  M.  Ktiempfen,  of  a 
cavalry  officer  who  fell  from  his  horse  and  pitched  on  the  right  parietal  bone.  He  had  vomi- 
ting and  syncope ; and  a total  want  of  recollection  came  over  him  of  every  thing  that  occurred 
the  day  previous  to  the  accident,  and  for  some  hours  after  it.  In  a few  days  he  was  sufficiently 
recovered  to  resume  his  duty,  but  never  regained  his  recollection  of  what  had  happened  during 
these  periods.  Such  an  effect  has  been  noticed  in  other  instances  of  injury  on  the  head. 

f Chap.  xvi.  sect.  2,  note. 

t Page  211.  He  recommends  minute  doses  of  tartar  emetic,  after  delivery,  as  a preventive. 


414 


COMPLEX  LABOURS. 


to  peritonitis,  even  where  blood  had  been  taken  freely ; and  Gooch*  gives 
a case  exemplifying  the  truth  of  these  observations.  Although  it  has  oc- 
curred to  myself  to  meet  with  a few  instances  of  peritoneal  affection  sub- 
sequent to  convulsions,  the  number  has  by  no  means  been  so  great  as  to 
have  impressed  my  mind  with  the  idea  of  the  latter  disease  having  any 
connexion  with  the  former,  had  not  such  a remark  been  made  by  high 
practical  authorities. 

Hysterical  Convulsions. — Nervous  and  irritable  women  are  liable  occa- 
sionally during  labour,  but  more  particularly  under  pregnancy,  to  convul- 
sive fits  of  a much  less  dangerous  kind  than  that  which  l have  just 
described,  which  seem  not  to  originate  in  pressure  sustained  by  the  brain, 
and  for  the  subdual  of  which  such  active  remedies  are  not  required.  In 
these  the  spasmodic  affection  is  confined  to  the  muscles  of  the  trunk  and 
extremeties,  seldom  affecting  the  face : there  is  not  the  same  strongly 
marked  disturbance  of  the  sensorium,  nor  the  same  turgescence  of  the  ves- 
sels of  the  head,  nor  the  same  hideousness  of  aspect. 

There  is  a sensation  of  globus,  palpitation  of  the  heart,  and  a discharge 
of  flatus  on  the  termination  of  the  fit.  The  muscles  of  the  back  seem  to  be 
the  principal  seat  of  spasm,  so  that  the  trunk  is  bent  backwards,  in  the 
form  of  an  arch;— a state  of  things  mentioned  both  by  Deweest  and 
Burns, J as  strongly  characteristic  of  the  hysterical  kind.  Such  cases  fre- 
quently depend  on  irritation  existing  in  the  intestinal  canal,  and  may  ge- 
nerally be  relieved  by  brisk  purging,  the  dashing  of  cold  water  on  the  face, 
and  warm  frictions,  or  stimulating  applications,  to  the  stomach,  abdomen, 
and  back. 

Many  of  the  antispasmodic  medicines  will  be  found  of  service  in  this 
variety,  and  an  assafoetida  injection  has  sometimes  at  once  cut  short  the 
disease. 


APOPLEXY  UNDER  LABOUR, 


and  during  the  last  few  weeks  of  pregnancy,  unattended  with  convulsive 
action,  is  sometimes,  though  very  rarely,  met  with.§  The  symptoms  are 
those  characteristic  of  the  same  disease  under  ordinary  states  of  the  sys- 

* Op.  Cit.,  p.  247. 

t Parag.  1239.  t Page  461. 

§ A case  of  this  kind  will  be  found  in  the  Liverpool  Medical  Journal  for  June,  1834,  by  Dr* 
O.  Roberts;  and  another  in  Cheyne’s  work  on  Apoplexy,  page  88,  by  Dr.  Kellie  of  Leith.  I 
have  only  seen  one  case  of  apoplexy  unattended  with  convulsions  in  pregnancy  ; this  was  fatal ; 
it  was  in  the  sixth  month,  and  was  a twin  gestation.  No  case  of  this  kind,  either  during  or 
after  labour,  has  come  under  my  observation. 


RUPTURE  OF  THE  UTERUS. 


415 


tem ; it  is  usually  followed  by  paralysis,  nor  does  the  case  require  any 
other  than  the  common  treatment. 

Both  during  the  continuance  of  the  convulsive  paroxysms,  as  well  as 
after  their  cessation,  while  the  patient  still  remains  in  a state  of  imperfect 
consciousness,  it  is  absolutely  necessary  that  the  bladder  should  be  care- 
fully attended  to;  as  it  may  become  inordinately  distended,  and  perhaps 
serious  mischief  may  ensue. 


3d.  LABOURS  COMPLICATED  WITH  RUPTURE  OF  THE  UTERUS. 


Occasionally  the  uterus  bursts,  its  structure  gives  way,  and  a rent  is 
formed  in  its  substance ; — an  accident  of  the  most  formidable  nature,  and 
which,  by  far  most  generally,  terminates  fatally.  Rupture  of  the  uterus 
is  certainly  a very  rare  occurrence,  but  there  can  be  no  doubt,  both  that  it 
has  often  been  the  undetected  cause  of  death,  and  also  that,  when  known 
to  the  attendant,  it  has  not  unfrequently  been  concealed  from  mistaken  feel- 
ings of  policy.*  The  rent  may  take  place  at  any  part  of  the  uterine  struc- 
ture— the  fundus,  the  body,  the  cervix,  or  the  mouth,  may  give  way.  It 
varies  also  considerably  in  its  direction,  being  sometimes  longitudinal, 
sometimes  transverse,  and  at  others  oblique.  The  vagina  may  be  impli- 
cated, or  remain  uninjured.  The  laceration  may  pass  through  the  whole 
texture  of  the  organ,  and  involve  both  membranes,  an  extensive  commu- 
nication being  made  at  once  with  the  abdominal  cavity ; or  the  peritoneum 
may  be  lacerated,  and  the  parenchyma  only  slightly  torn;f — or  again,  a 
large  rent  may  extend  through  the  inner  membrane  and  the  parenchy- 
matous structure,  while  the  peritoneum  continues  entire,  the  blood  which 
is  effused  being  pent  up  below  it,  and  not  extravasated  into  the  general 
cavity  of  the  belly. J It  is  most  usual  for  the  laceration  to  take  place 


* Barns  (p.  477)  states  that  its  frequency  has  been  calculated  at  one  in  940  cases.  Out  of 
48,719  cases,  however,  delivered  by  the  midwives  of  the  Royal  Maternity  Charity  within  the 
last  twenty-one  years,  partly  under  my  father’s  superintendence,  but  principally  under  my 
own,  (when  an  occurrence  of  the  kind  could  not  have  happened  without  our  knowledge,) 
we  have  only  had  eleven  instances  of  rupture  of  the  uterus  or  vagina,  being  one  in  4,429 
labours. 

t This  is  the  rarest  variety  of  uterine  laceration  ; but  instances  of  it  may  be  found  recorded 
by  Sir  C.  Clarke,  Transactions  of  a Soc.  for  Improvement  of  Med.  and  Chirurg.  Knowledge, 
vol.  iii.  p.  290 ; by  Prof.  Davis,  Obst.  Med.,  p.  1067  ; my  father,  Pract.  Obs.,  case  86,  part  i. 
p.  409 ; Mr.  Chatto,  Med.  Gazette,  1832,  p.  630;  Mr.  White,  Dublin  Journal  of  Med.  and 
Chem.  Science,  July,  1834,  p.  325  ; and  Mr.  Partridge,  Med.  Chirurg.  Transactions,  vol.  xix. 
p.  72.  These,  I believe,  are  all  that  are  on  record. 

t See  my  father’s  Pract.  Obs.,  case  81;  Velpeau,  edit,  de  Brux.,  p.  332;  Hamilton,  Pract. 
Obs.,  p.  376  ; Davis,  p.  1068  ; and  Steidell’s  first  case,  Med.  Comment.,  vol.  vi.  p.  123. 


416 


COMPLEX  LABOURS. 


through  all  the  structures  at  once.  The  rupture  may  be  instantaneous,  or 
more  gradual ; a large  rent,  sufficient  to  allow  the  child  to  escape  into  the 
abdomen,  may  happen  in  an  instant ; or  a small  aperture  may  first  be 
made,  and  gradually  increased  with  each  return  of  uterine  contraction, 
until  it  has  acquired  a size  sufficient  to  permit  the  passage  of  the  whole 
foetal  body  out  of  the  uterine  into  the  peritoneal  cavity. 

Causes. — Rupture  of  the  uterus  during  labour* * * §  may  be  produced  by  the 
violence  of  the  uterine  efforts  themselves — the  viscus  bursting  under  its 
own  inordinate  action  ;f — or  it  may  be  the  consequence  of  forcible  and 
improperly  conducted  attempts  to  turn,  under  a shoulder  or  other  presen- 
tation ; of  which  sad  catastrophe  I have  unfortunately  seen  more  than  one 
instance ; — or,  again,  it  may  be  caused  by  instruments,  in  the  hands  of  the 
ignorant,  the  careless,  or  the  inconsiderately  rash.  It  is  impossible  to 
believe  with  La  Motte,J  Levret,§  and  Crantz,||  that  the  struggles  or  con- 
vulsive movements  of  the  child  can  ever  occasion  it. 

This  accident  may  occur  to  women  bearing  a first  or  subsequent  chil- 
dren ; to  the  young,  as  well  as  those  more  advanced  in  life — to  the  ple- 
thoric and  the  debilitated — to  the  healthy  and  the  ailing.  But  out  of  the 
many  cases  to  which  I have  been  called,  I have  only  known  two  instances 
in  which  it  happened  during  a first  labourH.  It  may  take  place  as  well 
under  a head,  a breech,  or  a transverse  presentation,  and  at  any  period  of 
the  labour.  It  has  been  known  to  happen  at  the  very  commencement  of 
the  process,  when  the  os  uteri  had  not  acquired  a dilatation  equal  to  the 
diameter  of  a shilling.** 


* The  uterus  may  be  burst  under  pregnancy,  as  any  of  the  other  abdominal  viscera  might 
be,  by  force  applied  from  without,  such  as  the  being  run  over  by  a carriage,  and  the  like  acci- 
dent ; but  such  do  not  come  within  the  scope  of  the  present  observations. 

t Hamilton  (Pract.  Obs.,  p.  378)  states  that  he  saw  one  case  in  which  the  uterus  ruptured 
itself  under  a convulsive  fit ; and  he  therefore  regards  convulsions  as  an  exciting  cause ; but 
I do  not  know  any  other  instance  on  record  of  a similar  kind  ; and  we  cannot  but  look  upon 
these  two  occurrences  happening  together  in  the  same  labour  as  purely  accidental. 

$ Traite  des  Accoueh.,  1765,  parag.  596. 

§ L’Artdes  Accouch.,  1761,  p.  106. 

II  Commentarius  de  Rupto  in  partus  doloribus  fcetu  Utero,  1756,  parag.  8^  A transla- 
tion into  French  of  this  memoir  will  be  found  appended  to  Puzos,  Traite  des  Accouchemens, 
1759,  4to. 

^ Out  of  thirty-four  cases  noted  by  Collins,  seven  occurred  in  first  labours.  He  states  that 
he  was  for  a long  time  of  opinion  that  women  in  labour  of  a first  child  were  rarely  liable  to 
this  accident;  but  that  experience  has  convinced  him  this  was  an  error. — (Pract.  Treat,  on 
Mid.,  p.  305.) 

**  A preparation  of  ruptured  uterus  was  once  sent  to  my  father,  in  which  the  child  and 
membranes  had  passed  into  the  peritoneal  cavity  before  the  os  uteri  could  admit  two  fin- 
gers.— (Pract.  Obs.,  &,c.,  case  84.)  Most  likely,  in  this  instance,  there  was  disease  in  the 
uterine  structure — a softening  or  thinning  of  texture,  for  instance,  consequent  on  inflamma- 


RUPTURE  OF  THE  UTERUS. 


417 


Laceration  of  the  uterus  is  most  likely  to  happen  to  a patient  who  has 
had  three  or  four  children,  who  possesses  a slightly  distorted  pelvis,  and 
who  has  been  in  strong  labour  for  a number  of  hours. 

Although  the  rent  may  take  place  in  any  portion  of  the  organ,  its  most 
frequent  seat  is  at  the  neck,  either  at  the  posterior  part,  opposite  the  pro- 
minence of  the  sacrum,  or  anteriorly,  behind  the  symphysis  pubis.*  The 
direction  is  also  mostly  transverse,  or  slightly  oblique.  It  is  not  difficult 
to  account  for  this  being  the  most  usual  situation  of  the  injury;  for  since, 
during  the  latter  part  of  gestation,  the  neek  of  the  womb  rests  upon  the 
pelvic  brim,  if  the  promontory  of  the  sacrum  dip  too  far  forward,  or  the 
ridge  of  the  pubes  be  preternaturally  sharp,  it  is  reasonable  to  suppose  that 
the  uterine  structure  may  be  affected,  that  inflammation  may  occur  as  a 
consequence  of  pressure,  and  that  a thinning  or  softening  of  the  substance 
may  be  induced;  and  under  these  circumstances,  should  the  structure 
give  way  at  all,  it  is  likely  that  the  weakened  part  will  be  the  first  to 
suffer  .f 

Denman,  indeed,  says  that,  “ independently  of  disease,  the  uterus  may 
be  worn  through  mechanically,  in  long  and  severe  labours,  by  pressure 
and  attrition  between  the  head  of  the  child  and  the  projecting  bones  of  a 
distorted  pelvis  ; especially  if  they  be  drawn  into  points,  or  a sharp  edge.”J 
One  or  other  of  these  causes  may  explain  why  we  more  frequently  meet 
with  laceration  of  the  uterus  when  the  pelvis  is  slightly  contracted,  in  the 
conjugate  diameter  at  the  brim,  than  when  the  distortion  is  excessive . It 
must  not  be  forgotten,  however,  that  by  a fall,  or  other  accident,  the 
uterus  may  be  so  much  injured  as  to  induce  a degree  of  disease  that  will 

tion ; for  we  cannot  suppose  that  the  healthy  womb  would,  by  its  own  powers,  lacerate 
its  substance  before  the  membranes  of  the  ovum  had  given  way;  and  while  its  mouth  was 
undilated. 

* 11  is  very  rarely  that  the  fundus  gives  way,  unless  as  a eonsequence  of  violence  inflicted 
on  the  body  .externally ; or  perhaps  from  the  hand  of  the  attendant  in  endeavours  to  turn  the 
child, 

f In  the  last  case  but  one  of  ruptured  uterus  to  which  I was  called,  (Oct  23,  1840,)  dis- 
section showed  that  the  linea  ileo-pectinea,  where  it  traverses  the  pubes,  was  formed  into  a 
very  sharp  ridge,  that  there  were  a number  of  bony  prominences  jutting  from  the  inner 
surface  of  the  pubic  bones  towards  the  cavity,  and  one  especially,  situated  above  the 
left  thyroid  foramen,  which  was  so  pointed  as  to  pain  the  finger  when  hard  pressure  was 
made  on  it.  The  sacro-pubic  diameter  was  two  inches  and  three  quarters  in  extent.  It 
was  the  woman's  second  pregnancy;  the  first  child  had  been  delivered  by  craniotomy.  After 
a consultation  held,  labour  on  this  occasion  was  induced  in  the  eighth  month  by  the  exhibition 
of  four  doses  of  the  ergot.  The  membranes  broke  spontaneously,  three  hours  and  a half  before 
the  accident  occurred.  I was  sent  for  by  the  gentleman  in  attendance  immediately,  and  deli . 
vered  by  turning;  she  died  on  the  night  of  the  fourth  day.  See  Burns,  p.  471,  for  a some- 
what  similar  case. 

I Chap.  x.  seet.  7,  pa  rag.  8. 

53 


418 


COMPLEX  LABOURS. 


predispose  it  to  lacerate  at  that  spot  where  the  blow  was  inflicted,  when 
it  takes  on  itself  expulsive  action.* 

Symptoms. — The  symptoms  of  ruptured  uterus  are  strongly  character- 
istic of  some  violent  injury  having  been  sustained ; and  they  may  be 
divided  into  the  local  and  more  general  marks.  The  history  of  the  case 
will  be  somewhat  of  this  kind. 

A woman  who  has  probably  had  children  before — who  has  generally 
suffered  lingering  labours — who  we  know  possesses  a small  pelvis — and 
for  whose  safety  we  are  consequently  more  than  usually  solicitous — is  to 
all  appearance  going  on  well  in  labour,  having  borne,  with  fortitude  and 
good  spirits,  a number  of  strong  expulsive  pains ; when,  in  the  acme  of 
one  of  these  powerful  contractions,  she  suddenly  shrieks,  cries  out  that 
something  has  given  way  within  her,  and  expresses  herself  as  being  in 
violent  agony.f  From  that  time,  all  proper  uterine  action  ceases,  or  be- 
comes very  much  diminished. 

If  an  extensive  rent  be  formed  at  once,  the  probability  is  that  the  labour 
pains  will  be  instantly  suspended ; but  if  it  be  only  slight  in  the  first 
instance,  they  will  most  likely  be  continued  for  some  little  time,  though 
their  character  will  be  more  feeble,  and  with  each  return  of  contraction 
there  will  be  an  increase  in  the  laceration.  Should  the  pains  of  parturition 
entirely  cease,  their  place  will  be  supplied  by  a new  pain,  referred  to  one 
fixed  spot,  constant,  most  agonizing,  and  much  more  difficult  to  bear  than 
the  throes  of  labour. 

There  is  seldom  observed,  consequent  upon  the  accident,  a copious 
haemorrhage.  It  might  be  supposed  a priori , as  the  vessels  of  the 
uterus  are  so  large,  that  when  they  are  torn,  blood  would  be  poured 
out  rapidly  from  their  lacerated  cavities,  in  a somewhat  similar  way  as 
when  the  placenta  is  partially  separated  before  or  after  the  child’s  birth. 
But  this  is  not  the  case ; there  is  seldom  considerable  flooding  as  a conse- 
quence of  ruptured  uterus,  and  sometimes  there  is  but  little  or  no  increase 
of  discharge  whatever.];  Even  should  the  vessels  bleed  freely,  their  con- 
tents need  not  escape  externally ; for  the  head  of  the  child  may  be  so  block- 

* Ferfect  relates  an  instance  (case  78)  in  which  a fall,  six  weeks  previously,  seemed  ^o*Be 
the  predisposing  cause  of  rupture  during  labour. 

t Tt  is  said  that  this  rending  sensation  has  been  accompanied  by  a noise  distinctly  audible 
to  the  attendants  in  the  room;  but  as  I was  never  present  when  the  accident  happened,  I 
have  no  opportunity  of  verifying  or  refuting  the  assertion  by  my  own  observation.  (See  Ob- 
servations on  Ruptured  Uterus,  by  Dr.  Andrew  Douglas,  London,  1785,  p.  49  ; also  Dewecs, 
parag.  1382;  and  Perfect’s  Cases  in  Mid.,  vol.  ii.p.  GO.) 

t Hamilton  (Pract.  Obs.,  p.  377)  says,  according  to  his  observation,  that  when  the  rent  is 
transverse,  an  immense  effusion  of  blood  into  the  cavity  of  the  abdomen  follows;  but  that  longi- 
tudinal  lacerations  are  not  productive  of  the  same  effect. 


RUPTURE  OF  THE  UTERUS. 


419 


ing  up  the  pelvis  as  to  prevent  the  exit  of  the  fluid  through  the  vagina ; 
and  it  may  be  effused  into  the  cavity  of  the  abdomen* 

On  making  an  examination  soon  after  this  new  pain  is  complained  of, 
we  shall  usually  find  that  the  head,  which  could  be  easily  detected  at  our 
previous  examinations,  can  now  only  just  be  touched,  or  it  may  have 
receded  completely  out  of  the  reach  of  the  finger,  so  as  to  elude  our 
search.  This  is  owing  to  the  admission  of  the  child’s  body  more  or  less 
within  the  peritoneal  cavity,  through  the  rent  thus  accidentally  made. 
We  are  not,  however,  to  expect  this  as  a universal  symptom; — though, 
when  it  does  occur,  it  may  be  considered  one  of  the  strongest  diagnostic 
marks  we  can  observe, — because  it  is  not  unlikely  that  the  head  may  have 
previously  become  locked  in  the  pelvis,  having  been  forced  into  the  cavity 
by  the  contractions  of  the  uterine  fibres ; and  if  it  be  firmly  jammed,  it  is 
impossible  that  it  can  free  itself  so  as  to  recede* 

Occasionally,  then,  it  will  happen  that  the  whole  of  the  child’s  body  at 
once  escapes  through  the  rent  into  the  abdominal  cavity ; nay,  the  same 
strong  contraction  that  caused  the  rupture  has  expelled  both  child  and 
placenta  into  the  peritoneal  sac;  and  the  uterus  continuing  to  act,  they 
have  both  been  enclosed  in  a shut  cavity,  to  which  there  is  no  outlet.* 
Cases  are  on  record  also  where  the  same  contraction  that  caused  the 
laceration  expelled  the  child  into  the  world.f 

Whenever  the  foetus  has  thus  escaped  more  or  less  out  of  the  uterus 
into  the  cavity  of  the  abdomen,  its  limbs  maybe  traced  through  the  abdo- 
minal parietes  ; the  breech,  legs,  and  perhaps  the  arms,  may  be  felt  tolera- 
bly distinctly.^ 

The  symptoms  I have  just  enumerated  are  particular  signs,  and  belong 
exclusively  to  the  case  we  are  considering  ; but  there  are  others  of  a more 
general  character,  which  soon  take  place,  and  are  themselves  also  highly 


* In  a case  that  occurred  within  the  knowledge  of  my  father,  the  foetus  was  expelled  into 
the  belly  through  the  rent,  and  by  the  same  uterine  effort  the  placenta  was  thrown  into  the 
world  through  the  vagina. — (Pract.  Obs.,  part  ii.  case  217.)  I was  called  to  a case  of  ruptured 
uterus,  in  which,  although  the  head  originally  presented,  I found  on  my  arrival  the  breech 
offering  itself.  The  laceration  took  place  at  the  cervix,  implicating  also  the  vagina,  while  the 
ltoa£  was  entirely  above  the  brim;  the  upper  part  of  the  child  had  escaped  through  the  new- 
made  opening  into  the  abdominal  cavity,  and  the  fundus  continuing  to  contract,  the  breech 
was  forced  down  into  the  situation  the  head  had  originally  occupied  ; the  child’s  body  was 
thus  made  to  perform  an  evolution,  and  the  breech  passed  into  the  pelvis ; from  which  I ex- 
tracted it  with  some  difficulty. 

f See  Burns,  p.  470.  In  a case  of  recovery  after  this  fearful  accident,  related  by  Mr. 
Currie  of  Liverpool,  (London  Med.  Gazette,  Feb.  27th,  1836,)  the  breech  presented,  and  the 
laceration  took  place  between  the  expulsion  of  that  part  and  the  birth  of  the  shoulders. 

t The  being  able  to  trace  the  foetal  limbs  through  the  parietes  of  the  abdomen,  in  conjunc. 
tion  with  the  recession  of  the  head,  almost  or  entirely  out  of  the  reach  of  the  fingers,  is  to  be 
regarded  as  an  infallible  proof  of  this  dangerous  occurrence  having  taken  place. 


420 


COMTLEX  LABOURS. 


characteristic  of  the  accident.  The  general  symptoms,  indeed,  are 
exactly  such  as  we  should  expect  to  meet  with  in  cases  of  extensive 
injury  to  any  of  the  abdominal  viscera.  The  pulse  soon  flags,  it  becomes 
very  quick,  irregular,  and  so  feeble  as  to  be  scarcely  perceptible ; the 
respiration  becomes  hurried,  laboured,  and  painful ; the  countenance 
anxious  and  dejected  ; the  eyes  sunken,  dull,  and  inexpressive  ; the  belly 
swells  rapidly,  and  almost  immediately  becomes  very  tender  to  the  touch. 
Vomiting  of  a dark-coloured  matter  supervenes,  sometimes  almost  in- 
stantaneously, sometimes  at  a later  period ; there  is  generally  hiccough ; 
the  extremities  become  cold  and  insensible ; a cold  sweat  breaks  out  on 
the  face,  forehead,  neck,  and  chest;  and  if  delivery  be  not  effected,  the 
patient  will  almost  always  gradually  sink  in  a very  few  hours  from  the 
accident. 

Prognosis. — Although  a laceration  of  the  uterus  is  to  be  looked  upon 
as  the  most  dangerous  accident  that  can  happen  to  any  of  the  pelvic 
viscera  during  labour,  with  the  exception  only  of  a rupture  of  the  bladder, 
still  it  is  not  to  be  considered  necessarily  fatal ; many  cases  of  recovery 
are  on  record,  detailed  by  Heister,*  Peu,f  Douglas, J and  Kite  ;§  but,  to 
name  more  recent  authors,  the  late  Dr.  Hamilton||  met  with  one,  so  did. 
his  father.^!  Madame  La  Chappelle,**  Haden,fj*  Blundell,JJ  Frizel,§^ 
Dunn, mi  Currie,' 1H1  Birch,***  and  Smith  of  Maidstone, fff  besides  some 
others,  each  give  us  one.  Davis, JJJ  Collins, §§§  and  M’Keever,||||||  have 
noted  two ; and  my  father  has  seen  three.THHf  Thus,  although  the  acci- 

* Surgery,  part  ii.  sect.  5,  cap.  xiii.  sect.  14.  He  relates  it  as  communicated  to  him  by 
Rungius,  (evidently  a Latinized  name,)  who  was  a respectable  surgeon  at  Bremen.  The 
intestines  were  distinctly  felt  protruding  through  the  rupture  into  the  cavity  of  the  uterus 
after  the  child  was  extracted.  Rungius  kept  them  back  with  his  hand  till  the  organ  was 
sufficiently  contracted  to  prevent  them  prolapsing  again  ; and  the  woman  happily  recovered. 

f Pratique  des  Accouch.,  1694,  p.  341.  In  this  case  the  uterus  was  torn  and  pierced  in 
several  places  by  violent  efforts  to  deliver  ; the  neck  of  the  bladder  was  also  lacerated. 

t Observations  on  Ruptured  Uterus  1785;  case  of  Mrs.  Manning,  p..  7. 

§ Mem.  Med.  Soc.,  Lond.,  vol.  iv.  p.  253. 

II  Select  Cases  in  Mid.,  p.  138. 

^ Outlines  of  Midwifery,  3rd  edit.,  p.  348,  note. 

**  Annuaire  Med.  Chirurg.,  tom.  i.,p.  542. 

tf  Trans,  of  Society  of  Improvement  of  Med.  and  Chirurg.  Knowledge,  vol.  ii.  p.  184 

It  Obstetricy,  p.  704,  note. 

§§  Trans,  of  King  and  Queen’s  Coll.  Phys.,  Dublin,  vol.  ii.  p.  15. 

HU  Edinburgh  Med.  and  Surg.  Journal,  vol.  xl.  p.  72. 

irir  Med.  Gazette,  Feb.  27th,  1736,  p.  854. 

***  Med.  Chirurg.  Trans.,  vol.  xiii.  p.  357.  ttf  Ibid.,  p.  373. 

ttt  Obst.  Med.,  p.  1070.  W Pract.  Treatise,  p.  247. 

HUH  On  laceration  of  the  Womb  and  Vagina,  1824. 

ITiriT  Pract.  Obs.,  part  ii.  case  207,  and  two  following.  All  these  three  women  became  subse- 
quently pregnant ; one  of  them  my  father  attended  twice  afterwards  in  labour  ; another  died 
tf  flooding,  undelivered,  between  the  sixth  and  seventh  month  of  gestation.  On  opening  the 


RUPTURE  OF  THE  UTERUS. 


421 


dent  must  be  considered,  as  one  of  a very  formidable  character,  yet  we 
are  not  to  give  up  the  case  as  hopeless : we  are  both  authorized,  and 
bound  to  make  some  efforts  to  preserve  the  patient. 

Treatment. — There  is  but  one  mode  of  practice,  however,  that  offers 
the  least  chance  of  life — and  this  is  speedy  delivery.  The  instant  I knew 
the  accident  had  occurred,  I should  proceed  to  extract  the  child — provided 
delivery  could  be  accomplished — as  being  the  most  likely  way  to  save  the 
mother,  and  the  only  means  of  preserving  the  infant.*  If  the  head  has 
entered  the  pelvis,  and  has  not  retreated,  so  that  the  long  or  short  forceps 
can  be  used,  the  child  may  be  extracted  by  their  agency.  But  we  gene- 
rally find  that  it  has  receded  beyond  the  reach  of  that  instrument;  and 
we  must  then  introduce  the  hand  into  the  uterus,  follow  the  child’s  body 
through  the  rent  made  into  the  abdomen,  if  it  have  escaped,  search  for 
the  feet,  draw  it  by  their  means  back  through  the  same  opening  into  the 
cavity  of  the  uterus,  and  extract  it  per  vaginam.  If  it  should  happen  that 
after  the  breech  and  shoulders  are  born  the  head  remains  above  the  brim, 
and  will  not  pass  in  consequence  of  the  contraction  of  the  pelvic  bones, 
we  shall  be  compelled  to  open  it  behind  the  ear,  and  extract  it  as  I have 
before  directed.-)-  The  preservation  of  the  child  indeed  is  not  to  be  ex- 
pected, and  scarcely  to  be  hoped  for  under  these  circumstances,  for  in 

body  there  was  detected  at  the  anterior  part  of  the  uterus  a cicatrix,  running  in  an  oblique  direc- 
tion, which  evidenced  the  union  that  had  taken  place  after  the  rupture.  Frizell’s  patient  had 
one  child  afterwards  ; Dunn’s  had  two;  so  had  Lambron’s,  (vide  note  p.  424,  of  this  work;)  and 
Douglas’s,  it  would  appear,  had  three  or  four.  In  the  year  1839  I was  called  to  a patient, 
who  after  a very  lingering  labour,  had  been  delivered  of  her  first  child  by  craniotomy  seven 
hours  and  a half.  An  attempt  had  been  made  unsuccessfully  to  remove  the  placenta.  I found 
the  woman  much  exhausted;  the  uterus  was  firm,  the  placenta  wholly  within  it;  on  intro- 
ducing my  hand  into  the  vagina,  it  passed  through  a rent  in  the  back  part,  either  of  the  vagina 
or  cervix  uteri,  into  the  abdominal  cavity.  I felt  the  posterior  peritoneal  surface  of  the  uterus 
distinctly,  as  well  as  the  intestines.  1 withdrew  it,  again  introduced  it  in  a different  direc- 
tion, when  it  entered  the  uterine  cavity.  The  placenta  was  strongly  and  universally  adherent. 
I separated  it,  and  took  it  away,  with  some  difficulty.  No  blood  flowed  either  during  or  after 
the  operation;  nor  did  any  proper  lochial  appear,  but  in  their  place  a most  fostid  discharge 
came  on  and  lasted  till  the  twenty-first  day ; a portion  of  putrid,  fibrous  matter,  nearly  as  large 
and  as  thick  as  a woman’s  hand,  then  came  away,  certainly  no  part  of  the  placenta,  and  the 
discharge  ceased;  she  was  able  to  leave  her  bed  at  the  end  of  the  month;  five  weeks  after  her 
confinement  she  became  the  subject  of  melancholia,  which  at  the  end  of  a fortnight  disap- 
peared ; and  she  subsequently  recovered  perfectly.  Three  other  women  I have  delivered  who 
I expected  might  recover,  two  having  lived  a week,  and  one  six  days. 

* “ I attribute  the  successful  issue  of  this  case,  in  a great  measure,  to  the  promptness  with 
which  the  woman  was  delivered  after  the  accident  had  occurred.” — (Ramsbotham,  Pract. 
Obs.,  part  ii.  p.  489.)  The  recovery  of  the  patient  “ seems  in  a great  measure  to  depend  on 
the  speedy  removal  of  the  child  from  among  the  viscera.” — (Douglas  on  Ruptured  Uterus, 
p.  67.)  “ The  author  is  strongly  impressed  with  the  belief  that  nothing  but  immediate 
delivery  can  save  the  life  of  the  woman.” — (Hamilton,  Pract.  Obs.,  p.  383.) 

t Page  298. 


4-22 


COMPLEX  LABOURS. 


almost  every  instance  of  ruptured  uterus  on  record,  and  in  all  which  I 
have  myself  attended,  the  foetus  has  been  born  dead.* * * §  Levretf  insists 
upon  the  necessity  of  cutting  through  the  parietes  into  the  abdominal 
cavity  immediately  the  event  is  detected ; and  BaudelocqueJ  thinks,  if 
delivery  cannot  be  perfected  by  the  forceps,  that  this  mode  of  removing 
the  child  is  much  preferable  to  extracting  it  by  the  vagina.  He  limits 
delivery  by  the  feet  to  those  cases  where  they  are  found  at  the  os  uteri, 
or  where  the  child  remains  entirely  within  the  uterine  cavity,  or  where 
the  vagina  only  is  ruptured,  the  uterus  itself  being  uninjured.  I think 
myself  the  British  practice  far  superior  to  that  inculcated  by  Levret  and 
Baudelocque.  During  the  passage  of  the  child  from  the  abdomen  through 
the  uterine  rent,  great  care  must  be  taken  lest  any  folds  of  intestine  be 
brought  down  with  it,  and  involved  in  the  opening;  because,  on  the 
uterus  contracting,  they  would  necessarily  be  strangulated,  add  very 
much  to  the  present  suffering,  and  dissipate  the  slight  chance  of  safety 
still  remaining.^ 

Every  circumstance  connected  with  rupture  of  the  uterus  is  agonizing 
to  the  utmost  extent ; the  suddenness  and  awful  nature  of  the  accident,  the 
rapid  sinking  of  the  vital  powers,  and  the  almost  certain  loss  of  the  infant, 
all  combine  to  render  this  a case  of  most  aggravated  distress.  To  these 
may  be  added  the  horrible  feeling  experienced  in  the  delivery  by  the  feet, 
at  the  hand  being  introduced  into  the  centre  of  the  abdomen  of  a living 
person.  Nothing  can  be  more  appalling  than  the  sensation  communicated 
by  the  intestines  encircling  and  coiling  round  the  fingers ; but,  however 
horrifying  the  idea,  all  feelings  of  repugnance  must  give  way  before  a 
sense  of  duty.  It  is  seldom  under  laceration  of  the  uterus  that  the  perfo- 
rator can  either  be  necessary  or  available  as  a means  of  delivery  before 
the  body  of  the  foetus  is  extracted ; for  if  the  head  be  locked  in  the  pelvis, 
which  is  not  often  the  case,  the  labour  may  most  probably  be  concluded 
by  the  forceps;  and  if  it  remain  entirely  above  the  brim,  it  will  either  have 
receded  out  of  reach,  or  will  be  pushed  up  on  the  application  of  the  instru- 
ment, and  not  afford  sufficient  resistance  to  enable  us  to  perforate  the 
cranial  bones.  This  cause  of  disappointment  I have  myself  in  no  few  in- 
stances experienced ; and  have  found  turning,  therefore,  the  operation  most 
generally  applicable  to  this  emergency. 

As  soon  as  delivery  has  been  effected,  a large  dose  of  opium  or  mor- 

* Collins  states  (p.  247)  that  out  of  thirty-four  children  two  were  born  alive,  but  this  I 

should  look  upon  as  beyond  the  general  average  of  live  births. 

t L’Art  des  Accouchemens,  p,  105.  t Parag.  2177,  trans. 

§ In  Rungius’  and  Currie’s  cases,  as  well  as  many  others  on  record,  the  intestines  protruded 
through  the  laceration  into  the  uterine  cavity  ; and  Baudelocque  (parag.  2166)  informs  us  that 
they  were  actually  strangulated  in  a case  that  occurred  under  the  hands  of  M.  Percy. 


RUPTURE  OF  THE  UTERUS. 


423 


phia  must  be  given,  the  utmost  quietude  must  be  observed,  every  thing 
stimulating — unless  the  depressed  state  of  the  system  requires  the  admi- 
nistration of  some  cordial — must  be  avoided,  and  the  restorative  powers 
of  nature  must  be  trusted  to  for  the  recovery.  I know  no  medicines  but 
those  of  the  soothing  kind  that  are  likely  to  be  of  service ; and  no  other 
specific  means  can  be  adopted  until  inflammatory  symptoms  appear;  when 
the  case  must  be  treated  upon  common  principles. 

But  it  is  not  always  possible  to  deliver  the  patient  by  the  natural 
passages.  The  mouth  of  the  womb  may  be  rigid,  and  not  sufficiently 
dilated  to  admit  of  the  hand  being  introduced';  but  this  is  rare ; or  what 
is  more  probable, — especially  if  the  rent  be  in  the  fundus  or  near  it, — the 
uterus  may  have  expelled  the  child  and  placenta  entirely  into  the  abdomen, 
and  contracted  so  strongly  as  to  have  closed  its  cavity.  Under  such  a 
state  it  would  be  most  injudicious  to  endeavour  to  extract  the  child  in  the 
ordinary  way,  both  because  of  the  additional  hazard,  which  must  attend 
on  any  attempt  to  gain  an  entrance  into  the  uterine  cavity ; and  because, 
even  were  the  hand  admitted,  the  rent  through  which  the  child  had 
escaped  would  be  so  much  diminished  in  extent,  by  the  contraction  of 
the  parietes,  as  to  preclude  the  possibility  of  bringing  the  foetal  body  again 
through  it  without  considerably  increasing  it,  and  adding  to  the  original 
danger. 

In  these  perplexing  cases,  it  becomes  a point  of  much  nicety  to  deter- 
mine whether  the  patient  should  be  left  to  the  resources  which  nature  may 
supply,  or  whether  any  means  should  be  taken  for  relieving  the  abdomen 
from  the  presence  of  the  foetal  body. 

There  are  many  cases  of  reputed  rupture  of  the  uterus  on  record,  in 
which  the  child  has  been  left  in  the  cavity  of  the  abdomen,  and  has  been 
evacuated  in  a putrid  state  by  abcess,  the  woman  perfectly  recovering. 
I am  far  from  denying  the  possibility  of  such  a termination  to  the  case ; 
but  I should  look  upon  it  as  most  improbable ; and  I cordially  coincide 
with  Dewees*  in  the  opinion,  that  almost  all  these  cases  have  been 
instances  of  extra-uterine  conception,  and  not  of  impregnation  of  the 
womb,  attended  with  rupture  of  the  organ.f 

Feeling  as  I do  that  to  leave  the  child  in  the  cavity  of  the  belly  is 
almost  certain  death  to  the  mother,  I should  seriously  entertain  the  ques- 


* Parag.  1361. 

t The  cases  of  this  kind  least  liable  to  suspicion,  perhaps,  are  those  related  by  Baudelocque, 
(parag.  2149,)  when  it  was  believed  the  uterus  had  been  ruptured  by  a fall  in  the  fourth 
month  of  pregnancy;  after  which  the  foetus  was  evacuated  by  abscess,  through  the  abdominal 
parietes  ; and  those  given  by  Davis,  (p.  1072,)  which  occurred  under  the  notice  of  Dr.  Sims  and 
Mr.  Windsor. 


424 


COMPLEX  LABOURS. 


tion  whether  the  parietes  of  the  abdomen  should  be  divided,  and  the  child 
extracted  by  that  means,  or  whether  the  patient  should  be  abandoned  to 
the  chance  of  what  nature  might  effect;  and  the  answer  must  depend  en- 
tirely on  the  circumstances  of  the  individual  case.  If  she  were  in  tolerably 
good  spirits, — if  she  had  not  suffered  so  great  a shock  as  usual  from  the 
accident, — particularly  if,  after  explaining  to  her  what  had  occurred,  she 
were  anxious  for  the  operation  to  be  performed,  I should  have  no  hesita- 
tion in  undertaking  it.  But  if  I found  her  sinking, — if  the  powers  of  life 
were  ebbing  fast, — and  particularly  if  thirty  or  forty  minutes  had  elapsed 
since  the  rupture,  and  the  movements  of  the  foetus  had  quite  ceased, — I 
should  by  no  means  sanction  the  incision,  because  of  the  painful  nature 
of  the  operation ; and  because  I should  presume  it  would  avail  nothing, 
and  might  probably  hasten  her  death.  Much,  then,  must  be  left  to  the  judg- 
ment of  the  practitioner ; and  his  determination  must  depend  entirely  on 
the  state  of  the  patient,  and  the  probability  of  the  child’s  being  saved. 
For  the  sake  of  the  infant,  it  would  be  right  to  urge  the  operation  im- 
mediately after  the  accident  with  greater  force  than  if  half  an  hour  or 
longer  had  elapsed,  because,  while  there  is  a chance  of  the  child’s  survival, 
its  welfare  must  be  considered  as  well  as  that  of  the  mother ; but  after  its 
death,  the  mother,  of  course,  would  alone  interest  us.% 

Premonitory  symptoms. — Generally  laceration  of  the  uterus  takes  place, 
without  any  symptoms  indicating  even  the  probability  of  its  occurrence  ; 
but  many  premonitory  signs  have  been  noted  by  Crantz,f  Levret,J  Burns, § 
Hamilton, ||  Davis,1 TT  and  others,  as  forerunners  of  the  accident ; these  are 
all  most  unsatisfactory,  and  unfortunately  not  to  be  depended  on.  It 
would  be  most  desirable,  indeed,  if  some  infallible  precursor  of  this  dread- 
ful occurrence  were  discovered,  that  delivery  might  be  effected  before 
the  laceration  happened,  and  thus  the  peril  be  averted. 

We  certainly  may  fear  that  laceration  will  ensue,  if  the  woman  posses- 
sing a small  pelvis  is  in  labour  of  a third,  fourth,  or  fifth  child ; if  her  previous 
labours  had  been  lingering,  and  more  than  ordinarily  painful;  if  for  six  or 
eight  hours  she  have  been  suffering  strong  expulsive  throes,  attended  with 
little  progress;  if  she  complain  of  a violent  crampy  pain  in  one  particular 

* The  operation  of  gastrotomy  after  rupture  of  the  uterus  for  the  extraction  of  the  infant 
has  very  rarely  been  performed  ; but  there  are  the  histories  of  some  successful  cases  on  record; 
thus  M.  Thibaut  Desbois  of  Mans  published  one  in  which  the  mother  recovered. — (Journal  de 
Med.,  vol.  iii.  p.  448,  Mai,  1768.)  M.  Lambron  operated  in  this  manner  twice  on  the  same 

woman  : (Baudelocque,  trans.,  parag.  2180  ;)  the  last  time  saving  both  mother  and  child.  She 
became  pregnant  again,  and  was  delivered  of  a healthy  child  naturally.  In  vol.  v.  of  Journal 
Complementaire  du  Diet,  dcs  Sciences  Med.,  p.  189,  Dec.  1819,  a case  of  this  kind  is  given, 
operated  on  by  MM.  Bernard,  Latouche,  and  Josset,  in  which  the  woman  was  preserved. 

t De  Rupto  Utero,  parag.  xiv.  1 L’Art  dcs  Accouch.,  parag.  598. 

§ Mid.,  p.  492.  H Pract.  Obs.,  p.  385.  * * * § Obst.  Med.,  p.  1069. 


RUPTURE  OF  THE  UTERUS. 


425 


part  of  the  uterus,  increased  under  a contraction,  but  never  entirely  disap- 
pearing, particularly  if  that  should  be  the  spot  opposite  the  promontory  of 
the  sacrum,  or  behind  the  symphysis  pubis.  With  the  presence  of  such 
symptoms,  I should  consider  it  probable  that  the  uterus  had  received  some 
injury,  and  I should  fear  that  if  the  labour  were  allowed  to  go  on  unassist- 
ed, the  organ  might  rupture.  Under  these  circumstances,  I should  con- 
sider myself  fully  warranted  in  having  recourse  to  delivery  before  the 
woman’s  powers  began  to  flag,  provided  the  child  could  be  extracted  by 
the  forceps,  without  injury  either  to  itself  or  its  parent. 

Though  as  much  averse  as  any  person  can  be  to  unnecessary  instru- 
mental interference,  I have  applied  the  long  forceps  with  great  success  in 
some  cases  where  such  a state  of  things  was  present, — not  because  the 
patient  was  sinking,  but  because  of  this  fixed  and  agonizing  pain, — 
dreading  the  possibility  of  rupture  of  the  uterus;* 

I have  seldom  known  a case  in  which  the  uterus  ruptured  where  the 
attendant  was  not  more  or  less  blamed ; and  that,  as  may  be  gathered 
from  what  I have  advanced,  most  unjustly. 


4th.  LABOURS  COMPLICATED  WITH  LACERATION  OF  THE 

VAGINA. 

Laceration  of  the  vagina  is  often  complicated  with  rupture  of  the 
uterus ; but,  occasionally,  the  whole  of  its  coats  burst  while  the  uterus 
remains  entire,  and  the  child  escapes  more  or  less  into  the  abdominal 
cavity.f 

Such  cases  are  usually  attended  by  symptoms  similar  to  those  that  ac- 
company rupture  of  the  uterus ; they  are  almost  equally  dangerous,  and 
are  to  be  treated  exactly  on  the  same  principles. 

But  a laceration  of  some  of  the  fibres  of  the  mucous  membrane  and 
muscular  coat  at  the  back  part  of  the  vagina  sometimes  takes  place, 

* Levret,  Hamilton,  Davis,  and  others,  recommended  liberal  bleeding  when  such  symptoms 
arise  as  they  suppose  threaten  a laceration  of  the  womb;  Hamilton  and  Davis,  after  venesection 
administer  full  doses  of  opium.  Both  these  means  will  be  useful  to  quiet  inordinate  uterine 
action  ; but  I should  prefer  delivery  without  loss  of  time,  if  it  could  be  accomplished  without 
injury. 

t Laceration  of  the  vagina,  to  the  extent  of  allowing  any  part  of  the  child  to  pass  into  the 
peritoneal  cavity,  is,  as  far  as  I have  been  able  to  judge,  a much  rarer  accident  than  rupture  of 
the  uterus.  But  Merriman  (Synops.,  p.  35,  note)  mentions  having  seen  two  cases,  each  of 
which  was  occasioned  by  the  midwife  forcibly  dragging  the  child  swollen  with  putrid  air  into 
the  world  ; one  will  be  found  in  the  Med.  Chirurg.  Review,  July  1834,  p.  224,  transcribed  from 
Siebold’s  Journal;  M‘Keever  (Med.  Chirurg.  Review,  Dec.  1821,  p.  530)  met  with  one;  Ross 
(Annals  of  Med.  vol.  iii.  p.  277)  reports  one,  after  which  recovery  took  place;  the  woman  bo. 

54 


426 


COMPLEX  LABOURS. 


while  the  head  is  occupying  the  pelvis.  This  is  most  usual  in  first  labours, 
when  rigidity  exists,  and  the  parts  do  not  dilate  with  their  usual  degree  of 
ease. 

The  medical  attendant  may  perhaps  be  sensible  that  a laceration  has 
occurred ; but  it  may  take  place  when  neither  the  medical  man  nor  the 
patient  are  at  all  aware  of  what  has  happened,  the  pain  which  the  parts 
are  suffering  being  but  little  increased  by  the  fibres  giving  way.  After 
the  birth,  inflammation  will  supervene,  the  healing  process  will  be  esta- 
blished, and  in  the  next  labour  a small  cicatrix  may  perhaps  be  felt,  which 
may  give  the  first  indicatioij  of  the  previous  occurrence. 

Treatment. — If  the  laceration  were  to  a great  extent, — if  we  feared  it 
might  run  into  the  rectum,  or  up  to  the  os  uteri,  we  should  hasten  the  de- 
livery of  the  child  by  the  forceps,  provided  they  could  be  used  with  advan- 
tage ; but  if  it  were  trifling,  the  labour  must  be  allowed  to  proceed  in  the 
natural  way,  the  laceration  being  carefully  watched,  and  the  perineum 
most  assiduously  supported,  when  the  head  comes  to  rest  upon  it.  After 
labour  is  completed,  a poultice  may  be  applied : and  if  there  be  no  contra? 
indicating  symptoms,  a full  dose  of  opium  may  be  given ; and  the  bowels 
should  be  early  relieved. 


,5th.  LABOURS  COMPLICATED  WITH  RUPTURE  OF  THE 

BLADDER. 

A more  fatal  accident  even  than  rupture  of  the  uterus,  is  the  bursting  of 
the  bladder  during  labour,  and  the  evacuation  of  its  contents  into  the  peri- 
toneal sac.#  It  appears  to  me  that  this  accident  must  always  be  the  effect 
of  neglect  or  improper  interference ; it  very  seldom,  indeed,  or  never,  can 
occur  in  the  hands  of  a careful  and  judicious  surgeon.  The  kidneys  under 
lingering  labour  rarely  secrete  the  same  quantity  of  urine  in  the  same 
space  of  time  as  they  are  accustomed  to  do  in  the  ordinary  states  of  the 
system,  because  much  of  the  fluids  is  carried  off  by  perspiration ; and  the 
secretions  of  the  skin  and  urinary  organs  are  in  a great  degree  vicarious ; 

came  again  pregnant,  and  the  same  accident  occurred  at  the  same  part  of  the  vagina — she 
recovered  a second  lime  also;  and  my  father  giyes  a case  (part  i.  case  87)  in  which,  after  death, 
an  extensive  laceration  of  the  posterior  part  of  the  vagina  wTas  discovered  communicating  with 
the  cavity  of  the  belly,  but  not  implicating  the  uterus.  I was  called  to  a case  once,  in  which 
the  anterior  part  of  the  vagina  had  given  way  below  the  os  uteri,  and  the  child  had  escaped 
between  the  uterus  and  bladder  into  the  cavity  of  the  belly;  both  the  latter  organs  remaining 
uninjured.  I should  scarcely  have  supposed  one  or  other  of  these  organs  could  have  escaped 
a participation  in  the  accident,  if  dissection  had  not  positively  convinced  me  of  the  fact. 

* This  accident  is  fortunately  very  rare ; but  two  cases  to  which  my  father  was  called  will 
fce  found  detailed  in  part  i.  of  his  Pract,  Obs„,  cases  89  and  90, 


RUPTURE  OF  THE  BLADDER. 


427 


but,  at  the1  same  time;  the  action  of  these  organs  is  by  no  means  suspended  ; 
a certain  quantity  of  urine  is  constantly  distilling  through  the  ureters,  and 
the  bladder  becomes  at  length  distended.  If  this  distention  is  allowed  to 
proceed  beyond  a certain  point,  it  will  burst,  and  the  case  becomes  per- 
fectly hopeless. 

The  rash  or  careless  employment  of  instruments  under  a distended  state 
may  also  cause  laceration.  If  the  forceps  are  applied  while  the  bladder 
is  full,  the  action  of  the  instrument  is  very  likely  to  occasion  it  to  give 
way ; and  for  this  reason  I have  before  particularly  inculcated  the  neces- 
sity of  thoroughly  evacuating  this  viscus  before  any  attempts  at  delivery 
are  made. 

Symptoms . — When  laceration  of  the  bladder  has  taken  place,  the  symp- 
toms are  exceedingly  distressing  and  strongly  marked;  they  are  very  much 
like  those  characterizing  a rupture  of  the  uterus ; the  recession  of  the 
child,  however,  the  being  able  to  trace  its  limbs  through  the  abdominal 
parietes,  and  any  increase  of  discharge  through  the  vagina,  being  want- 
ing ; — they  are,  the  appearance  of  a sudden  and  violent  pain  in  the  region 
of  the  bladder,  accompanied  with  a shriek,  and  a declaration  by  the  pa- 
tient that  something  has  burst  within  her ; a rapid  sinking  of  the  powers 
of  life ; a general  tumefaction,  and  great  tenderness  of  the  abdomen.  The 
labour-pains — which  usually  cease  on  a rupture  of  the  uterus— continue 
for  an  uncertain  time,  till  they  decline  as  a consequence  of  exhausted 
powers.  The  particular  symptoms  present  in  this  case,  and  absent  in 
rupture  of  the  uterus,  are,  a loss  of  the  vesical  tumour  which  before  could 
be  felt  distending  the  abdominal  parietes,  and  in  its  stead  a more  diffused 
swelling  of  the  belly,  combined  with  some  degree  of  fluctuation. 

Since  rupture  of  the  bladder  is  so  universally  fatal,  and  since  it  can 
usually  be  prevented  if  proper  attention  be  paid,  it  becomes  our  duty, 
under  lingering  labour  particularly,  to  keep  a watchful  eye  over  its  con- 
dition; and  if  it  become  immoderately  full,  to  relieve  it  by  the  catheter.  It 
is  possible,  however,  that  the  urethra  may  be  a little  turned  to  one  or  other 
side,  out  of  its  regular  straight  course,  by  the  pressure  of  the  head,  and  dif- 
ficulty may  be  experienced  in  introducing  a silver  instrument ; if  such  an 
impediment  should  exist,  it  must  not  be  overcome  by  force,  but  a flexible 
male  catheter  must  be  used  instead. 

It  has  never  occurred  to  me  to  meet  with  a case  in  which  it  was  neces- 
sary to  puncture  the  bladder  during  labour,  owing  to  an  inability  to  intro- 
duce the  catheter ; but  such  may  doubtless  possibly  occur ; and  if  so,  the 
puncture  should  be  made  immediately  above  the  symphysis  pubis,  in  the 
hope  that  the  peritoneum,  drawn  up  by  the  rising  of  the  bladder  from  the 
pelvis,  may  escape  injury. 

Treatment. — Regarding  this  accident  as  unavoidably  fatal,  and  con- 


428 


COMPLEX  LABOURS. 


sidering  that  the  woman  will  most  certainly  die,  I think  that  our  principal 
care  should  be  directed  to  the  preservation  of  the  child,  and  to  endeavour 
to  extract  it  before  its  death,  by  the  forceps,  or  by  turning. 

If  there  were  indications  of  its  being  still  living,  I should  consider  the 
use  of  the  perforator  in  most  cases  unjustifiable,  and  it  would  become  a 
question  whether,  if  no  means  of  delivery  per  vias  naiurales  could  be  re- 
sorted to,  compatible  with  its  safety,  the  Caesarean  section  should  not  be 
performed. 

Such  a mode  of  delivery,  however,  should  never  be  contemplated  while 
the  woman’s  powers  remain  at  all  vigorous,  or  the  uterine  contractions 
continue  active;  for  so  long  there  is  a chance  both  of  the  child’s  life  being 
preserved  in  utero,  and  also  of  the  labour  being  naturally  terminated. 

The  death  of  the  child,  when  it  does  occur,  is  dependent  on  the  ex- 
hausted state  of  the  mother’s  system,  and  not  upon  any  destroying  influ- 
ence existing  within  its  own  person. 

The  child,  then,  having  been  extracted,  although  our  solicitude  for  the 
mother’s  preservation  be  wrought  up  to  the  highest  pitch,  I fear  any  farther 
efforts  to  save  her  will  be  fruitless  and  disappointing.  I cannot  coincide 
with  a great  authority  in  this  city,  who  has  suggested  the  possibility 
of  opening  the  abdominal  cavity,  sponging  out  the  extravasated  urine, 
cleansing  the  peritoneum  by  ablutions  of  warm  water,  drawing  up  the 
bladder,  placing  a ligature  around  the  lacerated  opening,  and  hoping  for 
a successful  issue.*  I would  prefer  abandoning  the  woman  to  her  fate, 
certain  and  fearful  as  it  is,  to  attempting  such  a means  of  prolonging  her 
existence,  upon  the  principle  that  1 would  rather  sit  quietly  at  her  side,  and 
watch  her  gradually  sink  by  the  hand  of  nature,  than  myself  be  the  instru- 
ment of  hastening  her  end. 


6th.  LABOURS  COMPLICATED  WITH  SYNCOPE  NOT  PRODUCED 
BY  HAEMORRHAGE  OR  LACERATION  OF  THE  GENITAL  OR- 
GANS. 


Both  during  and  after  labour,  women  become  occasionally  the  subjects 
Of  syncope,  unconnected  either  with  haemorrhage  or  laceration  of  any  of 
the  organs  more  immediately  concerned  in  parturition.  In  women  of  a 
delicate  habit,  nervous  and  hysterical,  slight  faintings  under  the  first  stage 
of  labour  are  by  no  means  uncommon ; and  in  the  higher  ranks  of  life, 
therefore  such  complications  are  most  frequently  observed.  They  are 
also  not  unusually  met  with  in  the  abodes  of  poverty,  where  a want  of 

* 


See  Blundell’s  Obstct.  by  Castle,  p.  179. 


SYNCOPE. 


429 


proper  ventilation  and  sufficient  nourishment  combines,  perhaps,  with  an 
habitual  use  of  ardent  spirits,  to  destroy  the  vigour  of  the  system,  and  in- 
capacitate it  from  bearing  up  against  the  exertion  attendant  upon  labour. 
Such  cases  require  but  little  consideration ; the  vital  powers  must  be  sus- 
tained at  a certain  point  by  the  stimulus  either  of  warmth,  fresh  air,  easily 
digestible  nutriment,  or  by  the  judicious  use  of  wine,  spirits,  sether,  or 
ammonia. 

If  organic  disease  exist  in  any  of  the  viscera,  particularly  those  of  the 
thorax,  sudden  death  may  take  place,  consequent  on  the  violent  struggles 
attendant  on  the  expulsive  pains;  an  aneurism,  or  an  abscess,  may  burst; 
or  the  heart  may  be  choked,  or  its  action  otherwise  impeded.* 

But  a more  simple  cause  of  syncope  after  the  child’s  birth,  independently 
of  haemorrhage,  consists  in  the  collapse  consequent  on  the  rapid  abstrac- 
tion of  that  pressure  from  the  abdominal  viscera  and  large  vessels  of  the 
trunk,  to  which  they  had  been  so  long  accustomed.  When  treating  of 
artificial  delivery  under  placental  presentations,  I referred  to  this  sudden 
change  in  the  relative  situation  of  the  contents  of  that  cavity,  as  adding, 
in  no  small  degree,  to  the  danger  of  the  case ; and  I have  known  faintness 


* I was  once  requested  to  be  present  at  the  inspection  of  the  body  of  a woman,  about  forty 
years  old,  who  had  died  suddenly  in  labour  of  her  first  child.  She  had  been  for  seven  years 
subject  to  great  difficulty  of  breathing,  with  cough,  which  had  latterly  increased,  and  the 
sputum  had  been  occasionally  streaked  with  blood.  Some  hours  after  the  membranes  had 
ruptured,  while  standing  by  the  bed-side,  during  a uterine  contraction,  she  seized  hold  of  her 
attendant’s  arm,  and,  without  uttering  an  expression,  she  fell  on  the  floor  dead.  On  opening 
the  body,  we  found  in  the  two  cavities  of  the  pleurae  nearly  three  pints  of  serum;  the  lungs, 
independently  of  their  compressed  state,  were  healthy ; the  pericardium  also  contained  a con- 
siderable  quantity  of  fluid. 

On  another  occasion  I was  requested  by  an  old  pupil  to  assist  him  in  investigating  the  cause 
of  death  in  a patient,  aged  twenty-eight,  who  suddenly  expired  immediately  after  having  given 
birth  to  her  fourth  child.  She  had  been  for  three  or  four  years  subject  to  violent  palpitations, 
and  much  difficulty  of  breathing,  on  the  least  exertion,  even  walking  slowly  upstairs;  she  had 
constant  cough,  and  occasionally  expectorated  small  quantities  of  blood.  My  friend  was  not 
called  until  the  os  uteri  was  entirely  dilated;  the  labour  was  unusually  easy;  the  child  was 
born  an  hour  after  he  entered  the  room;  and  the  same  pain  which  expelled  the  breech,  also 
threw  off  the  placenta.  She  appeared  not  to  have  suffered  much  from  fatigue,  and  inquired 
concerning  the  sex  of  the  child.  While,  however,  her  attendant  was  tying  the  funis,  he  ob- 
served  that  she  was  attacked  with  a slight  convulsion ; and  before  he  could  get  round  to  the  side 
«f  the  bed  near  which  her  head  lay,  she  had  ceased  to  breathe.  The  uterus  was  firmly  con- 
tracted, and  contained  a very  small  quantity  of  coagula;  the  viscera  of  the  abdomen  were  re- 
markably healthy  ; the  lungs  were  healthy  in  structure,  but  gorged  with  blood;  the  heart 
was  small,  and  very  flaccid  ; the  mitral  valve  was  much  thickened,  and  the  communication 
between  the  left  auricle  and  ventricle  would  only  just  admit  the  end  of  the  little  finger.  There 
were  about  five  ounces  of  serum  in  the  pericardium.  These  cases  would  teach  us  to  watch 
a patient  narrowly  under  labour,  in  whom  there  had  previously  existed  any  symptoms  of 
organic  disease  either  of  the  heart,  the  lungs,  or,  indeed,  of  any  other  organ  connected  with 
the  respiratory  or  circulating  systems. 

fv  • 


430 


COMPLEX  LABOURS. 


and  death  occur  quickly  after  the  process  of  labour  had  been  naturally 
completed,  when  there  was  no  hsemorrhage  to  account  for  the  fatal  result, 
and  when  dissection  neither  discovered  any  organic  disease,  nor  threw  the 
least  light  on  the  immediate  cause  of  dissolution. 

Such  attacks  of  syncope  most  frequently  follow  rapid  labours ; and  pa- 
tients of  a relaxed  fibre,  whose  minds  possess  a gloomy  turn, — especially 
those  who  have  entertained  deeply-rooted  apprehensions  with  regard  to 
their  recovery, — are  most  usually  the  subjects  of  this  dangerous  affection. 
My  father  states,  that  it  is  observed  more  frequently  when  the  child  is 
still-born,  and  refers  it  partly  to  despondency,  the  consequence  of  such  an 
aggravated  disappointment.*  The  liberal  admission  of  fresh  air,  placing 
the  head  and  shoulders  rather  below  the  level  of  the  other  parts  of  the 
body,  the  exhibition  of  repeated  small  doses  of  stimuli,  the  application  of 
warmth  to  the  extremities,  abdominal  friction,  and  especially  the  adapta- 
tion of  a properly  contrived  broad  bandage,  girt  tightly  round  the  person, 
seem  to  offer  the  most  effectual  means  of  restoring  the  tone  of  the  circu- 
lating system. 


7th.  LABOURS  COMPLICATED  WITH  PROLAPSUS  OF  THE  FUNIS 

UMBILICALIS. 


Prolapsus  of  the  funis  umbilicalis  by  the  side  of  the  head,  Plate  L.  fig. 
138,  or  breech,  sometimes  occurs  during  labour.  The  loop,  however, 
cannot  descend  until  after  the  membranes  have  ruptured ; and  usually  it 
passes  down  the  moment  the  liquor  amnii  is  evacuated.  The  longer  the 
cord  is,  the  more  likely  is  this  accident  to  happen ; and  should  it  have 
gravitated  to  the  os  uteri,  and  collected  there  in  a fold,  it  is  scarcely  pos- 
sible to  prevent  the  coil  being  carried  down  into  the  vagina  by  the  rush 
of  the  escaping  fluid. 

Such  an  occurrence  brings  with  it  not  the  least  danger  to  the  mother ; — 
the  labour  goes  on  as  well  as  if  it  had  not  happened ; for  since  the  space 
occupied  by  the  fallen  funis  is  most  inconsiderable,  it  cannot  impede  the 
regular  advance  of  the  process.  But  the  child  must  always  be  placed  in 
greater  or  less  jeopardy  ; the  peril  is  generally  extreme,  and  entirely  de- 
pendent on  pressure.  Since  the  life  of  the  foetus  is  sustained  by  the  cir- 
culation through  the  cord,  any  interruption  to  the  free  passage  of  the  blood 
must  produce  hazard ; and  if  it  be  suspended  for  any  length  of  time  conti- 
nuously, death  will  ensue,  as  surely  as  if  breathing  were  prevented  after 

* Pract.  Obs.,  part  i.  p.  207. 


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PROLAPSUS  OF  THE  FUNIS  UMBILICALIS.  431 


births*  and  it  therefore  becomes  a matter  of  great  moment  that  we  should 
adopt  «ome  plan  for  its  preservation.  Not  that  it  is  absolutely  necessary 
the  foetus  should  perish  because  the  funis  prolapses;  but  the  chances 
are  much  against  its  being  born  living,  unless  means  are  taken  to  pro- 
tect it.f 

Diagnosis. — There  will  be  no  difficulty  in  detecting  the  cord  hanging  in 
the  vagina.  By  its  softness,  smoothness,  and  roundness,  and  particularly 
by  its  pulsation, — should  the  circulation  be  still  carried  on, — it  may  be  dis- 
tinguished both  from  any  part  of  the  child,  as  well  as  from  any  of  the 
maternal  structures. 

Treatment. — If  the  pulsation  have  entirely  eeased  for  some  time, — es- 
pecially if  the  cord  be  external,  and  have  become  cold  and  flaccid, — there 
ean  remain  no  doubt  of  the  child’s  death.  The  continuance  of  the  funis 
in  the  vagina  is,  under  such  circumstances,  of  no  importance;  and  the  labour 
may  be  allowed  to  proceed  uninterfered  with.  But  if  the  arteries  be  still 
beating,  whether  in  a natural  manner  or  more  feebly,  it  is  right  that  we 
should  attempt  to  guard  the  vein  as  well  as  them  from  the  pressure  which 
they  must  more  or  less  experience  before  the  birth  is  perfected. 

With  this  intention,  four  methods  have  been  proposed : — carrying  the 
prolapsed  cord  to  that  part  of  the  pelvis  where  there  is  not  room,  and  where 
it  will  be  most  out  of  the  way  of  injury ; — turning  the  child,  and  delivering 
by  the  feet ; — returning  the  funis,  and  keeping  it  above  the  presenting  part 
until  the  foetus  is  partly  in  the  world  ; — and  delivering  by  the  forceps  as 
early  as  practicable. 

It  will  seldom  be  possible  to  preserve  the  funis  from  pressure  by  carry- 
ing it  to  one  or  other  side  of  the  pelvis ; for  the  volume  of  the  foetal  head 
is  so  nearly  adapted  to  the  capacity  of  the  pelvic  cavity,  as  to  leave  but 
little  space  unoccupied.  This  mode  of  proceeding,  then,  is  very  unsatisfac- 
tory, because  but  of  partial  benefit ; and  in  few  cases  can  it  be  trusted  to. 
Turning  the  child,  and  delivering  by  the  feet,  has  received  the  sanction  of 
most  obstetrical  authorities  of  the  present  day,  provided  the  presence  of 
the  funis  at  the  os  uteri  be  discovered  before  the  membranes  break,  or  it 
prolapse  while  the  head  remains  entirely  above  the  brim  ; the  os  uteri  being 
in  a dilated  or  easily  dilatable  condition.  Thus  Denman  J counsels  us, 
“ if  the  child  be  living,  and  the  presenting  part  remain  high  up  in  the  pelvis, 
— especially  if  the  pains  have  been  slow  and  feeble, — it  will  generally  be 

* Mauriceau  (Maladies  des  Femmes  Grosses,  livre  ii.  chap,  xxvi.)  supposed  the  exposure 
of  the  funis  to  the  cold  air  occasioned  the  child’s  death  ; but  this  is  evidently  erroneous. 

f Collins  (p.  346)  states,  that  out  of  ninety-seven  cases  of  prolapsed  funis  which  occurred 
in  the  Dublin  Lying-in  Hospital  during  his  mastership,  twenty-four  children  were  born  alive; 
and  ofsixty-six  during  Dr.  Clarke’s,  seventeen  were  born  alive. 

t Chap,  xviii.  sect.  3. 


432 


COMPLEX  LABOURS. 


better  to  pass  the  hand  into  the  uterus,  to  turn  and  deliver  by  the  feet,  using, 
at  the  same  time,  the  precaution  of  carrying  up  the  descended  funis,  that 
it  may  be  out  of  the  way  of  compression.”  But  he  afterwards  utters  a 
sentiment  which  would  render  the  instruction  just  quoted  almost  a dead 
letter,  in  these  words : “No  attempts  to  save  the  child  are  on  any  account 
to  be  made,  but  such  as  can  be  practised  without  the  chance  of  injuring 
the  mother.”* 

Burns  f says,  “As  soon  as  the  os  uteri  will  admit  the  introduction  of 
the  hand,  the  child  should  be  turned  but  if  the  presentation  be  advanced 
before  we  are  called,  he  recommends  “ removing  the  cord  to  that  part  of 
the  pelvis  where  it  is  least  apt  to  be  compressed;”  or  what  is  still  better, 
pushing  it  above  the  head,  because  “ this  is  less  violent,  and  safer,  than  at- 
tempts to  turn  in  an  advanced  stage  of  labour.”  Dewees  J tells  us,  if  the 
cord  prolapses,  “ turning  may  be  had  recourse  to — 1st,  When  the  uterus 
is  sufficiently  dilated  or  dilatable  for  the  operation  ; 2nd,  When  the  head 
is  still  enclosed  in  the  uterus  ; 3rd,  When  there  is  no  deformity  of  pelvis  to 
defeat  the  object  of  the  operation.”  Gooch, § after  premising  that  we  are 
not  justified  in  adopting  any  measure  which  will  endanger  the  life  of  the 
mother,  adds,  “ If  we  detect  a presentation  of  the  funis  when  the  os  uteri 
is  nearly  dilated,  the  membranes  entire,  and  the  parts  in  a relaxed  state, 
no  one  would  here  hesitate  to  turn  and  deliver,  as  it  may  be  done  with  ease 
and  safety.”  Campbell  ||  thinks,”  that  of  all  the  methods  proposed  for 
managing  these  cases  when  the  passages  are  prepared,  or  when  the  labour 
is  not  too  far  advanced,  turning  is  decidedly  the  most  proper ; but  this 
practice  is  not  unexceptionable.”  Hamilton  If  supposes  we  are  bound  to 
turn,  if  we  detect  a presentation  of  the  funis  before  the  membranes  rup- 
ture ; but  that  we  are  not  warranted  in  doing  it  afterwards. 

I have  thought  it  right  to  cite  the  opinions  of  these  eminent  practitioners 
at  length,  because  they  are  at  variance  with  my  own,  and  because  I wish 
to  put  the  case  as  fairly  before  the  student  as  I can.  No  argument  that 
I have  ever  heard  has  inclined  me  to  adopt  their  practice  as  a general 
principle  ; and  I perfectly  agree  with  Baudelocque,**  that  “ although  the 
accident  is  dangerous,  the  precept  of  delivering  instantly,  by  turning  the 
child,  if  adhered  to  indiscriminately,  is  not  less  so.”  He  advises,  that 
nothing  should  be  done  until  we  ascertain  what  course  nature  is  likely  to 
take,  and  the  degree  of  compression  the  umbilical  cord  is  suffering;  for 
he  thinks  that  the  natural  expulsion  is  often  more  rapid  than  the  extrac- 


* Seel.  4. 

§ Compend.  p.  239. 

**  Parag.  1122,  transl. 


f Princip.  of  Mid.  p.,  388. 
11  System  of  Mid.,  p.  320. 


X System  of  Mid.,  p.  262. 
IT  M S.  Lect.  1821. 


PROLAPSUS  OF  THE  FUNIS  UMBILICALIS.  433 


tion  could  be.  Conquest*  seems  adverse  to  turning  under  these  circum- 
stances ; nor  does  Blundellf  nor  Collinsf  sanction  the  practice.  Merri- 
man§  states,  that  turning  can  only  be  resorted  to  under  a combination  of 
the  four  following  circumstances  : — pulsation  in  the  cord,  proving  the  life 
of  the  child  ; its  head  not  having  yet  entered  the  pelvis ; the  pains  not 
being  strong ; and  there  existing  a relaxed  state  of  the  external  parts,  to 
admit  of  the  ready  extrication  of  the  head  ; and  indeed,  if  delivery  by  this 
means  is  ever  undertaken,  Merriman’s  judicious  rules  should  be  rigidly 
adhered  to.  I would  even  venture  to  add,  that  under  this  favourable  state 
of  things,  no  man  would  be  justified  in  terminating  the  labour  manually, 
unless  he  had  acquired  by  practice  some  experience  in  the  operative  de- 
partment of  his  profession* 

The  objections  which  I take  to  this  mode  of  proceeding  depend  partly 
on  the  hazard  in  which  the  mother  must  be  involved,  under  every  case  of 
turning,  however  favourable  the  attendant  circumstances,  and  however 
skilfully  the  operation  is  performed ; and  partly  on  the  danger  which  the 
child  must  suffer  from  compression  of  the  umbilical  cord  itself  during  the 
passage  of  its  shoulders  and  head  through  the  pelvis ; and  this  danger  will 
be  extreme  if  the  pelvis  be  of  small  dimensions,  or  the  soft  parts  preterna- 
turally  rigid. 

The  practice  I would  recommend  for  the  adoption  of  the  young  sur- 
geon, provided  the  subsidence  of  the  funis  be  discovered  before  the  mem- 
branes break,  is  to  keep  the  patient  perfectly  quiet  in  one  posture, — to  pre- 
vent her  moving  off  the  bed, — to  caution  her  strongly  against  exerting  her 
voluntary  efforts, — not  to  leave  the  chamber  on  any  account, — and  to  be 
most  careful  in  preserving  the  bag  of  membranes  perfect.  The  moment 
it  has  ruptured,  to  introduce  two  or  three  fingers  of  the  left  hand,  or  the 
whole  hand,  if  necessary,  into  the  vagina, — to  carry  the  loop  up  above 
the  presenting  part  of  the  head, — and  to  retain  it  there  until  the  next  pain 
comes  on,  in  the  hope  that  the  head  will  be  propelled  somewhat  down- 
wards, while  the  funis  remains  above.  Should  it,  however,  again  de- 
scend, another  attempt  may  be  made ; the  fingers  need  not  be  withdrawn 
until  two  or  three  pains  have  been  suffered,  and  it  is  quite  probable  that 
the  head  will  then  have  passed  down  so  low  as  to  preclude  the  likelihood 
of  the  cord  again  prolapsing.  We  shall  often,  however,  be  disappointed 
by  the  loop  again  appearing  as  soon  as  we  remove  our  fingers:  if  that 
should  be  the  case  after  the  cord  has  been  returned,  a small  piece  of  soft 
sponge,  as  advised  by  Hogben||  and  Hopkins,' H may  be  introduced,  to  act 

* Outlines,  1837,  p.  135.  t Obst.  by  Castle,  p.  610. 

t Pract.  Treatise,  p.  344.  § Synopsis,  p.  96. 

||  Obstetric  Studies,  p.  62.  ^ Accoucheur’s  Vade-Mecum , p.  193. 

55 


434 


COMPLEX  LABOURS. 


as  a stay  on  which  it  may  rest.  This  mode  of  proceeding  I have  two  or 
three  times  found  efficacious ; and  both  Gooch  and  Blundell  have  suc- 
ceeded in  saving  the  child  by  such  means. 

Mauriceau*  did  not  overlook  this  cause  of  danger  to  the  foetus,  and  he 
recommended  that  the  descending  loop  should  be  passed  up  by  the  end  of  the 
fingers ; and  if  it  would  not  remain  above  the  head,  but  descended  again 
as  soon  as  the  hand  was  removed,  that  a piece  of  soft  linen  should  be 
introduced  on  which  it  might  rest ; that  another  piece  of  linen  steeped  in 
warm  wine  should  be  carried  up  to  the  mouth  of  the  womb,  to  prevent  the 
funis  becoming  chilled ; and  if  these  means  do  not  succeed  in  preserving 
the  cord  above  the  head,  to  turn  the  child  with  great  care,  and  deliver  by 
the  feet,  provided  that  operation  could  be  accomplished  without  endanger- 
ing the  mother.  Dr.  Colin  Mackenzief  wrapped  the  prolapsed  fold  in  a 
leathern  purse,  with  a mouth  that  closed  by  a running  string,  and  carried 
both  within  the  uterus  together.  This  last  method  possesses  no  superi- 
ority over  the  piece  of  sponge;  and  it  is  not  impossible  that  the  vessels  of 
the  funis  might  be  so  compressed  by  their  envelope  as  to  suspend  the  flow 
of  blood  through  them.  The  late  Sir  Richard  Croft,  knowing  the  diffi- 
culty of  preserving  the  coil  of  cord  above  the  head,  advised  that  it  should 
be  carried  by  the  hand  into  the  uterus,  and  suspended  on  a limb,  which 
would  effectually  prevent  its  future  descent.  He  published  two  cases, J in 
which  he  practised  this  method  successfully,  and  informed  Dr.  Denman 
that  he  had  also  met  wdth  others  equally  fortunate.  His  suggestion,  how- 
ever, has  not  been  generally  followed ; and  I cannot  myself  recommend 
it  because  of  the  difficulty  of  accomplishing  the  object,  and  because  there 
must  always  be  some  risk  to  the  mother  in  the  introduction  of  the  hand 
within  the  uterus.  The  passing  the  hand  into  the  uterine  cavity,  indeed, 
is  never  to  be  adopted  without  grave  occasion,  and  a tolerable  certainty 
of  being  able  to  accomplish  the  end  for  which  it  was  undertaken. 

Should  the  membranes  have  broken  sometime  before  the  patient  is  first 
seen,  the  same  means  will  avail,  if  the  head  be  still  above  the  pelvic  brim. 
But  if  it  have  descended  within  the  scope  either  of  the  long  or  the  short 
forceps,  and  the  pulsation  in  the  umbilical  arteries  be  quick,  weak,  and 
intermittent,  (particularly  if  it  should  be  suspended  during  each  uterine 
contraction,)  while  the  progress  of  the  labour  is  slow,  one  or  other  of 
these  instruments  may  be  employed  to  facilitate  the  birth. § In  their  appli- 
cation, however,  we  must  be  extremely  careful  that  the  funis  is  not  pinched 
between  the  head  and  the  blade,  else  we  shall  run  into  the  very  danger 

* Livre  ii.  chap.  xxvi.  t Denman,  loco  citato. 

t Lond.  Med.  Journ.,  1786,  page  38. 

§ All  the  authorities  I have  mentioned  advise  delivery  by  the  forceps  if  the  head  is  in  the 
pelvis,  the  labour  progressing  slowly,  and  the  soft  parts  relaxed. 


DESCENT  OF  THE  HAND  BY  SIDE  OF  THE  HEAD.  435 


we  seek  to  avoid,  and  our  interference  will  be  highly  injurious,  instead  of 
useful.  The  extraction  must  be  as  rapid  as  is  consistent  with  the  mother’s 
safety. 

It  is  always  desirable,  when  the  funis  descends,  to  inform  the  patient’s 
friends  of  the  great  probability  existing  that  the  child  may  be  born  still, 
and  to  require  that  the  common  means  for  its  resuscitation  should  be  in 
readiness  on  its  expulsion ; and  if  she  herself  is  inquisitive  about  the  extra- 
ordinary attention  we  think  it  necessary  to  pay  her,  we  may  candidly  con- 
fess to  her  that  the  navel-string  has  fallen  down ; and  add,  that  the  acci- 
dent does  not  in  the  least  endanger  her  safety,  but  that  our  solicitude  is  for 
the  preservation  of  her  babe. 

If  the  funis  prolapse  by  the  side  of  the  breech,  and  the  vessels  be  suffer- 
ing compression,  traction  may  be  made  to  terminate  the  labour  more 
speedily ; and  if  it  pass  down  while  the  child  lies  transversely,  turning 
must  be  had  recourse  to ; — the  operation  being  undertaken,  not  because 
the  cord  descends,  but  because  of  the  unfortunate  situation  of  the  infant. 


8th.  LABOURS  COMPLICATED  WITH  DESCENT  OF  THE  HAND 
BY  THE  SIDE  OF  THE  HEAD  OR  BREECH. 


Descent  of  the  hand  by  the  side  of  the  head  or  breech  is  another  com- 
plication of  labour,  by  no  means  so  serious  as  the  case  last  considered, 
but  which  occasionally  is  productive  of  much  embarrassment.  One  hand 
only  may  prolapse,  Plate  L.  fig.  139,  or  both  may  at  the  same  time 
descend.  It  is  owing  to  the  original  position  of  the  foetus  in  utero.  I 
have  already  shown  that  the  most  usual  situation  of  the  arms  is  their 
being  crossed  upon  the  chest ; but  that  sometimes  one,  and  occasionally 
both,  are  placed  against  an  ear  : and  when  this  is  the  case,  on  the  evacua- 
tion of  the  liquor  amnii  the  descent  may  take  place. 

Though  not  dangerous  to  the  life  either  of  the  mother  or  her  offspring, 
this  accident  is  in  a degree  unfortunate  for  both ; — for  the  mother,  be- 
cause the  hand  occupies  a certain  quantity  of  space,  and  may  therefore 
proportionably  retard  the  labour ; — for  the  foetus,  because  the  pressure  on 
the  cartilaginous  structure  of  the  wrist  may  so  injure  the  limb  as  to  be  of 
serious  eventual  consequence ; and  this  especially  if  both  prolapse.  I have 
not  myself,  however,  in  any  case  seen  much  injury  result. 

It  is  not  difficult  to  detect  the  hand  at  the  brim  of  the  pelvis,  even  be- 
fore the  membranes  break.  There  is  no  part  of  the  body  with  which  it 


436 


COMPLEX  LABOURS. 


is  likely  to  be  confounded,  except  the  foot;  and  the  marks  I have  before 
enumerated  (p.  306,)  will,  if  borne  in  mind,  be  sufficient  to  distinguish 
the  one  limb  from  the  other. 

Treatment . — I have  before  directed  that,  whenever  the  hand  was  detected 
at  the  os  uteri,  an  accurate  examination  should  be  instituted  to  determine, 
as  soon  as  possible,  whether  the  shoulder  was  above ; or  whether  the  head 
or  some  other  part  was  presenting ; because  our  treatment  entirely  depends 
on  the  information  we  then  acquire.  Thus,  if  the  shoulder  present  or  the 
foetus  lie  otherwise  transversely,  turning  must  be  had  recourse  to,  which 
operation  is  not  necessary  if  either  the  head  or  the  breech  offer  themselves 
to  the  finger.  Should  the  case  prove  such  as  we  are  now  considering, 
our  duty  is  to  keep  the  prolapsed  limb  above  the  presenting  part,  that  as 
little  impediment  as  possible  may  exist  to  the  easy  expulsion  of  the  foetus. 
With  this  view,  on  the  rupture  of  the  membranes,  the  foetal  hand  may  be 
embraced  between  the  first  two  fingers  of  our  left  hand,  and  returned  with- 
out force  or  violence  within  the  os  uteri : it  may  there  be  kept  until  two  or 
three  pains  have  propelled  the  head  sufficiently  low  to  preclude  the  proba- 
bility of  a fresh  descent.  If  we  withdraw  our  fingers  immediately  we 
have  passed  it  up,  the  next  pain  will  again  protrude  it,  and  we  may  find  it 
requisite  to  return  it  many  times.  Should  we  be  foiled  in  keeping  it  out 
of  the  way  in  this  manner,  a piece  of  sponge  may  be  used,  as  recom- 
mended when  the  funis  prolapses ; and  if  it  gives  us  continued  trouble, 
rather  than  irritate  the  vagina  or  os  uteri,  we  had  better  allow  it  to  remain 
down,  and  take  the  chance  of  its  being  slightly  swollen.  It  is  not  neces- 
sary to  deliver  instrumentallv,  merely  because  the  hand  is  in  the  vagina ; 
but  if  the  pelvis  be  narrow  in  its  diameter,  and  especially  if  both  hands  are 
protruded,  so  much  room  may  be  occupied  by  them  as  materially  to  inter- 
fere  with  the  easy  passage  of  the  head ; and  such  symptoms  of  exhaustion 
may  possibly  be  induced  as  will  require  the  application  of  the  forceps,  or 
even  the  use  of  destructive  instruments,  to  terminate  the  labour, 

I am  pretty  well  persuaded  that  many  of  those  cases  which  we  some- 
times hear  of,  where  the  foetal  hand  presents  in  the  vagina,  and  it  is  supposed 
that  the  shoulder  has  been  raised,  and  the  head  brought  to  the  pelvic 
brim,  have  been  mistaken,  and  that  the  child  did  not  originally  lie  trans- 
versely, but  that  the  presentation  was  the  hand  by  the  side  of  the  head. 
I have  myself  more  than  once  heard  the  ease  with  which  this  evolution 
could  be  effected  mentioned,  and  the  superiority  of  this  mode  of  turning 
over  that  commonly  practised, — and  which,  indeed,  I have  recommend- 
ed,— strongly  insisted  on ; and  I have  always  suspected  some  error  in  the 
diagnosis : for  I know  by  experience  how  difficult  it  is  to  push  up  the 


MONSTERS. 


437 


shoulder,  and  bring  the  head  to  the  os  uteri,  when  the  membranes  have 
been  some  time  ruptured. 

By  referring  to  Plate  XLIY,  fig.  127,  it  will  be  perceived  how  easily  a 
simple  case,  such  as  I am  now  describing,  might  be  converted  into  one  of 
the  most  difficult  in  obstetric  surgery ; for  if  the  hand  be  brought  fully 
down,  so  as  to  appear  externally,  under  the  supposition,  for  instance,  that 
it  was  a foot,  the  head  will  very  likely  be  canted  over  one  ilium,  the  shoul- 
der and  chest  will  be  impacted  in  the  brim  of  the  pelvis,  and  a transverse 
presentation  will  be  formed,  which  will  require  the  introduction  of  the  hand, 
and  the  version  of  the  foetus,  before  the  labour  can  be  completed  : and  this 
should  be  an  extra  warning  to  us  perfectly  to  assure  ourselves  of  the 
position  of  the  child  before  we  interfere  by  traction  at  a limb. 


9th.  MONSTERS. 


The  development  of  those  irregular  formation  termed  Monsters  offers 
many  curious  objects  for  physiological  speculation,  and  some  of  interest 
also  to  the  practical  obstetrician : in  both  of  these  points  of  view,  therefore, 
the  subject  deserves  from  us  a little  consideration. 

Varieties. — The  word,  in  itself  not  perhaps  the  most  appropriate  that 
could  be  chosen,  has  very  improperly  been  applied  to  the  subjects  of 
disease,  such  as  appears  occasionally  in  after  life.  Thus  the  hydroce- 
phalic foetus  is  by  some  considered  as  a monster.  If  used  at  all,  however, 
it  should  strictly  be  confined  to  those  instances  in  which  some  great 
deviation  from  normal  structure  is  observed,  either  as  the  result  of  ori- 
ginal natural  formation,  confusion  of  the  organs  of  two  separate  children, 
or  irregular  or  diseased  action  of  a specific  kind,  such  as  can  only  exist 
in,  and  influence  the  organization  of,  the  foetus  in  utero.  BufFon’s  arrange- 
ment is  the  most  simple,  as  well  as  natural.  He  divides  these  productions 
into  four  varieties  ; — 1st,  those  in  which  there  is  a deficiency  of  parts  ; 
2nd,  those  which  are  redundant  in  organs ; 3rd,  where  the  parts  are  mis- 
shapen ; and  4th,  where,  although  the  organs  may  be  naturally  formed, 
they  are  misplaced. 

1st.  Deficiency  of  Parts. — Of  all  the  irregularities  of  monstrosity,  in- 
stances in  which  there  exists  a deficiency  of  parts  are  most  commonly 
met  with ; and  this  deficiency  may  exist  in  many  organs.  Among  those 
that  can  be  brought  under  the  examination  of  the  eye,  the  mouth  and 
lips  are  perhaps  most  frequently  the  seat  of  this  anormal  development. 
Sometimes  there  is  a simple  fissure  in  the  upper-lip,  forming  the  single 
hare-lip ; at  other  times  there  is  a double  fissure,  and  a want  of  a greater 


438 


COMPLEX  LABOURS. 


or  less  portion  of  the  palate ; sometimes,  again,  the  palate  is  faulty,  while 
the  lips  are  perfect.  Not  unfrequently,  also,  there  is  some  imperfection 
in  the  genitals.  The  anterior  part  of  the  bladder  and  the  parietes  of  the 
abdomen,  just  above  the  pubes,  have  been  found  wanting ; so  also  has  a 
portion  of  the  muscles  and  integuments  round  the  navel.  In  the  former 
case,  the  mucous  lining  of  the  bladder  is  continuous  at  its  circumference 
with  the  skin,  and  forms  a soft,  red,  sensitive  protuberance  in  the  pubic 
region ; the  ossa  pubis  do  not  meet,  and  the  recti  muscles  are  separated 
to  some  extent.  Such  an  extensive  malformation  could  not  exist  without 
disturbing  the  arrangement  of  the  genital  organs.  In  the  latter,  the  intes- 
tines in  the  neighbourhood  of  the  umbilicus  appear  to  have  no  covering 
but  the  peritoneum,  and  the  chorion  and  amnion  continued  from  the 
placenta.  Often  a large  portion  of  the  bowels  is  received  into  the  cord 
itself ; and  cases  are  on  record  in  which  the  whole  contents,  both  of  the 
abdomen  and  chest,  were  without  the  protection  of  their  usual  parietes. 
The  septum  between  the  ventricles  of  the  heart,  and  occasionally  the 
diaphragm,  have  been  deficient,  or  imperfect.  Sometimes  one  or  both 
arms,  at  others  the  legs,  are  scarcely  formed  at  all ; and  when  this  is  the 
case,  Nature  seems  to  make  up  for  the  deficiency  by  granting  an  extra 
growth  to  other  parts ; thus,  in  a foetus  preserved  in  the  London  Hospital 
Museum,  the  head  and  trunk  are  nearly  twice  the  natural  size,  while  the 
arms  and  legs  are  not  more  than  three  inches  long.  A want  of  the 
spinous  processes  of  three  or  four  contiguous  vertebrae,  is  not  a very 
uncommon  specimen  of  monstrosity.  This  constitutes  spina  bifida . 
There  is  usually  a soft  fluctuating  tumour  in  the  situation  of  the  mal- 
formed bones,  caused  by  water  contained  within  the  sheath  of  the  spinal 
marrow.  A midwife  under  my  superintendence  delivered  a woman,  a 
few  years  since,  of  twins,  each  labouring  under  spina  bifida  situated  low 
in  the  lumbar  vertebrae. 

But  the  most  interesting  and  singular  variety  of  deficient  organization 
is  exemplified  in  what  is  denominated  the  acephalous  monster.  In  this 
there  is  a total  want  of  the  bones  at  the  side  and  upper  part  of  the  cranium, 
as  well  as  of  the  brain  and  the  membranes  ordinarily  covering  it.  The 
basis  cranii  is  ill-shaped,  and  covered  by  a membrane  continuous  with 
the  integuments.  There  is  no  forehead,  but  the  skull  runs  backwards 
from  the  superciliary  ridge.  Sometimes,  under  the  membrane  at  the  base 
of  the  skull,  there  is  a quantity  of  soft  pulpy  matter ; but  more  frequently 
the  spinal  marrow  commences,  as  it  were,  abruptly.  The  preparations 
of  the  acephaloid  foetus  (which  have  been  multiplied  ad  infinitum , and 
specimens  of  which  may  be  found  in  every  museum,)  prove  that  the  case 
is  by  no  means  very  rare ; and  they  show  also  that  the  brain  is  not  essen- 
tial to  our  being  while  in  utero : for  many  of  these  children  have  arrived 


MONSTERS. 


439 


at  the  full  intra-uterine  size — nay,  some  are  actually  larger  than  an  ordi- 
nary foetus ; as  if  nature  had  intended  to  compensate  for  the  loss  of  the 
brain  by  allowing  an  exuberant  growth  to  the  body.  In  these  instances 
the  nerves  are  well  formed,  and  even  those  of  the  senses  which  ordinarily 
terminate  in  the  cerebral  mass  itself — such  as  the  optic — are  not  wanting. 
Acephaloid  children  have  been  known  to  live  some  hours,  and  even  days. 

I myself  saw  one  alive  thirty-six  hours  after  its  birth,  which  cried,  (though 
feebly,)  sucked,  and  seemed  to  perform  all  the  animal  functions  much 
more  perfectly  than  could  have  been  supposed.  The  spinal  marrow  has 
been  found  wanting  in  some  cases,  when  the  brain  wras  deficient.  There 
is  a woman  now  living  in  Double  X Place,  Globe  Road,  Mile  End,  who 
has  had  six  children,  and  each  alternate  one  has  been  acephalous,  the 
others  healthy,  and  born  living.  It  has  been  observed  by  her  attendant, 
that  with  each  of  the  monstrous  foetuses  there  has  been  an  excessive 
qauntity  of  liquor  amnii;  not  so,  however,  with  the  others. 

2nd.  Redundancy  of  parts. — Organs  are  not  unfrequently  redundant: 
thus  occasionally  there  are  supernumerary  thumbs,  fingers,  or  toes ; such 
an  irregularity  being  sometimes  confined  to  one  limb,  sometimes  affecting 
all.  It  10  ©vidontlj'  bulli  —..a j — *-  11  ,J’  ’ T ■ 

merely  because  it  possesses  a toe  or  a finger  more  than  the  natural 
number;  for  the  very  word  conveys  a horrible,  or  at  least  an  unpleasant, 
impression.  It  is  worth  remark,  that  this  deviation  from  natural  formation 
sometimes  runs  in  families.  Meckel  (Pathol.  Anatomy,  vol.  i.  p.  19)  has 
observed  this ; there  is  a curious  case  of  the  same  kind  in  the  fourteenth 
volume  of  the  Medical  Gaz.,  p.  65 ; and  two  similar  instances  have  come 
under  my  own  eye.  In  the  year  1831,  two  children  were  brought  to  my 
house,  twin  boys,  of  a fortnight  old,  one  of  them  with  a supernumerary 
finger  and  toe  on  each  hand  and  foot,  the  other  with  only  one  extra  finger 
on  the  right  hand ; the  toes  had  apparently  well-formed  joints,  by  which 
they  were  connected  to  the  metatarsal  bones ; the  fingers  merely  hung  by 
a pellicle  of  skin.  I saw  the  mother  afterwards,  and  found  she  had  a 
supernumerary  finger  and  toe  on  each  hand  and  foot,  with  perfect  joints, 
and  capable  of  motion.  She  told  me  she  had  borne  twenty-one  children 
—that  all  the  girls  but  one  were  born  with  extra  fingers  and  toes ; but 
only  one  of  the  boys  besides  the  twins  was  affected  in  the  same  manner. 
She  also  said  her  mother  and  one  of  her  sisters  were  the  subjects  of  the 
same  kind  of  irregularity.  The  other  case  much  resembled  this. 

Sometimes  a larger  and  more  important  member  than  a finger  or  toe 
is  supernumerary.  Thus  Sir  E.  Home  has  described,  in  the  80th  volume 
of  the  Philosophical  Transactions,  an  Indian  child  which  had  two  heads, 
united  together  at  their  crowns,— the  upper  one  being  inverted.  The 
subject  died  of  the  bite  of  a rattle-snake,  when  it  was  above  four  years 


440 


COMPLEX  LABOURS. 


old.  It  was  found  that  the  two  skulls  were  nearly  of  the  same  size — 
equally  complete  in  ossification.  “ The  frontal  and  parietal  bones,  instead 
of  being  continued  over  the  top  of  the  head,  meet  each  other,  and  are 
united  by  a circular  suture.  The  two  skulls  a;*e  almost  equally  perfect  at 
their  union  ; but  the  superior  skull,  as  it  recedes  from  the  other,  becomes 
imperfect,  and  many  of  its  parts  are  deficient.  The  number  of  the  teeth 
is  the  same  in  both.  There  is  no  septum  of  bone  between  the  crania,  so 
that  the  two  brains  must  have  been  contained  in  one  bony  case.”  The 
dura  mater  of  each,  however,  was  continued  across,  so  as  to  divide  the 
cerebral  masses  from  each  other,  and  their  membranes  were  perforated 
by  a number  of  large  vessels  by  which  the  upper  brain  was  nourished. 
The  skull  was  deposited  in  the  Hunterian  Museum,  and  is  now  in  posses- 
sion of  the  Royal  College  of  Surgeons. 

In  the  lower  animals,  monstrosities  occur  much  more  frequently  than 
in  man ; and  the  domesticated  are  more  obnoxious  to  these  irregularities 
than  those  in  the  wild  state.  Monstrous  pigs,  sheep,  puppies,  kittens, 
ducks,  and  chickens,  are  to  be  seen  in  every  collection  of  specimens 
devoted  to  the  elucidation,  of  the  subject  of  reproduction. 

the  sternum  and  abdomen.  Plate  LI,  figs.  140  and  141,  the  originals  of 
which  are  in  the  London  Hospital  Museum,  show  the  possibility  of  such  a 
confusion.  Nor  are  such  specimens  by  any  means  singular ; but  many 
similar  are  preserved.  Instances,  indeed,  are  not  wanting,  of  individuals 
variously  connected  by  nature,  surviving  their  birth,  and  even  living  to  ma- 
turity. The  far-famed  Hungarian  sisters,  who  were  born  in  Szony,  on  Oc- 
tober 26,  1701,  and  exbited  in  most  countries  of  Europe,  form  an  instance 
in  point.  These  girls  were  united  at  the  lower  part  of  their  loins  and  sacra ; 
but  instead  of  standing  back  to  back,  the  faces  and  bodies  were  placed 
half  sideways,  in  regard  to  each  other.  They  had  but  one  anus  and  one 
vulva ; their  viscera  were  all  double,  except  that  the  two  vagina?  united 
at  their  extremity,  and  the  two  recta  had  a similar  arrangement.  They 
were  not  equally  strong,  nor  of  equal  plumpness,  and  were  separately 
affected  by  hunger  and  the  calls  of  nature;  one  was  more  sickly  than  the 
other,  and  often  suffered  convulsions,  while  the  other  was  well.  One  often 
slept  while  the  other  was  awake.  They  lived  till  they  w’ere  nearly 
twenty-two  years  old,  and  menstruated  at  different  times.  They  died 
almost  at  the  instant. 

We  have  lately,  in  Britain,  had  an  opportunity  of  seeing  an  example 
somewhat  analogous  to  the  sisters  of  Hungary,  in  the  persons  of  the  Sia- 
mese twins,  who  were  born  in  May  1811,  and  exhibited  here  in  the  year 
1829.  These  boys  were  connected  by  a band  about  four  inches  long  and 
eleven  in  circumference,  situated  at  the  lower  part  of  the  sternum,  in- 


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MONSTERS. 


441 


volving  the  ensiform  cartilages,  and  possessing  at  its  lower  face  an  um- 
bilicus. The  length  of  the  band  allowed  them  to  turn  a little  sideways 
toward  each  other.  Their  nervous  systems  seemed  to  act  more  in  unison 
than  in  the  case  of  the  sisters ; for  they  both  slept  at  the  same  time,  and 
one  could  not  be  awakened  without  rousing  the  other ; their  pulses  were 
not  always  alike.  Hunger  affected  both  simultaneously;  they  both  pre- 
ferred the  same  kind  of  food,  and  were  both  satisfied  with  nearly  the 
same  quantity,  and  at  the  same  time.  But  the  vascular  systems  were 
distinct,  or  had  but  slight  communication;  for  asparagus  eaten  by  the  one 
did  not  impregnate  with  its  peculiar  odour  the  urine  of  the  other;  and  not 
the  least  pulsation  could  be  distinguished  in  the  band.  Three  or  four 
other  cases  of  double  foetuses,  who  lived  for  different  periods,  are  on 
record. 

Instances  also  are  recorded  of  the  union  of  a perfect  with  a partially 
developed  body,  of  which  A-Ke,  a Chinese,  sixteen  years  old,  may  be 
adduced  as  an  example.  He  had  the  loins,  nates,  upper  and  lower  extre- 
mities, of  a small  parasitical  brother  escaping  from  the  abdomen  between 
the  umbilicus  and  the  sternum.  This  prodigy,  I believe,  was  shown  in 
England  some  years  ago,  and  small  models  of  his  person  must  be  familiar 
to  every  one  who  has  had  the  curiosity  to  inquire  into  this  subject. 
Another  case  very  similar  to  the  last  is  related  by  Ambrose  Pare,  whose 
testimony,  although  he  deals  in  many  most  marvellous  stories,  is,  in  this 
instance,  at  least,  not  to  be  treated  lightly.  The  man  exhibited  himself 
in  Paris  in  1530,  was  forty  years  old,  and  had  growing  out  of  his  abdo- 
men a smaller  body,  perfect  in  all  its  parts,  but  wanting  the  head  and 
shoulders.  Pare  has  given  a drawing  of  this,  as  well  as  many  other 
monstrous  productions,  some  highly  probable,  but  most  of  them  absurd,  and 
perfectly  incredible; — and  Palfyn  gives  the  history  of  a man  having  a 
small  body  attached  in  the  same  way ; in  this  instance,  also,  there  were 
arms  external,  and  the  head  only  was  wanting.  Winslow  relates  that  he 
saw  a girl  of  twelve  years  old,  well  formed,  and  of  the  common  size,  with 
the  abdomen  and  lower  extremities  of  another  body  hanging  from  the  left 
side  of  the  epigastric  region ; and  in  the  79th  volume  of  the  Philosophical 
Transactions  there  is  the  account  of  a well-made  Gentoo  boy,  who  had 
the  pelvis  and  lower  limbs  of  a little  brother  suspended  from  the  pubes. 

Rueffe,  Pare,  and  Palfyn,  all  speak  of  a man,  alive  in  1519,  from  whose 
abdomen  a small  though  well-formed  head  appeared  to  grow;  and  Win- 
slow saw,  in  1698,  an  Italian,  who  had  another  head,  much  less  than  his 
own,  connected  to  the  chest  below  the  cartilage  of  the  third  rib.  The 
man  felt  any  impression  on  this  extra  head. 

Bartholin,  who  saw  the  person,  and  Zaccias,  relate  the  case  of  an  indi- 
vidual named  Lazarus  Colloredo,  cet,  28,  of  common  stature,  and  well 
56 


442 


COMPLEX  LABOURS. 


formed,  who  had  a deformed,  twin  brother,  John,  hanging  by  the  chest 
from  the  low^er  part  of  the  sternum.  His  head  was  larger  than  that  of 
Lazarus : he  had  two  arms,  with  three  fingers  on  each  hand,  but  only 
one  lower  extremity.  Respiration  was  hardly  perceptible,  but  there  was 
evident  pulsation  in  the  thorax ; he  was  nourished  by  the  food  taken  in  by 
Lazarus. 

Again,  an  imperfect  body  has  been  found  entirely  enclosed  within 
another.  In  the  Gentleman’s  Magazine  for  December  1748,  mention  is 
made  of  a child  born  with  a large  bag  extending  from  the  perineum  to 
the  toes,  which  in  a few  days  burst,  and  a mass  of  florid  flesh  protruded,  in 
which  were  distinctly  perceptible  a hand  and  foot,  with  perfect  fingers 
and  toes;  but  no  organs  could  be  traced,  or  any  rudiments  of  either  sex. 
Richerand  mentions  a lad  named  Bissieu,  who  died  at  thirteen  years’  old, 
and  who,  from  his  earliest  infancy,  had  a tumour  on  the  left  side  of  the 
lower  part  of  his  abdomen,  w?hich  was  very  painful.  He  was  seized  with 
fever  and  increase  of  pain  in  the  prominent  part,  and  voided  by  stool 
purulent  and  foetid  matter,  and  a ball  of  hair;  after  which  he  soon  sank. 
The  tumour  was  found  to  consist  of  a cyst,  having  a recent  communica- 
tion with  the  transverse  colon,  and  containing  the  rudiments  of  a foetus. 
There  were  discovered  a brain,  spinal  marrow,  very  large  nerves,  mus- 
cles, and  the  skeleton  of  the  head,  vertebral  column,  pelvis,  and  imperfect 
limbs,  with  a short  umbilical  cord  attached  to  the  mesocolon.  No  organs 
of  digestion  or  respiration,  urinary  or  generative,  could  be  found.  The 
case  was  drawn  up  at  length  by  M.  Dupuytren ; and  drawings  were 
made  by  MM.  Cuvier  and  Jadelot ; and  a detailed  account  was  published 
in  the  “ Bulletin  de  I’Ecole  de  Medecine ,”  “ Gazette  de  Sante ,”  1804,  and 
some  other  works  of  the  period.  A somewhat  similar  case  was  published 
by  Mr.  George  Young,  in  the  first  volume  of  the  Medico-Chirurgical 
Transactions;  it  was  of  a child  whom  he  saw  frequently  during  life,  in 
consequence  of  a tumour  in  the  abdomen,  which  gradually  increased  till 
his  death ; he  survived  nine  months.  A cyst  was  found  occupying  a large 
portion  of  the  abdomen,  which  contained  four  pints,  fourteen  ounces,  of 
greenish  limpid  fluid,  and  an  imperfectly  formed  foetus  adhering  to  it  by 
a conical  process  arising  from  the  umbilicus.  The  surface  was  covered 
with  that  sebaceous  matter  so  usually  found  on  the  skin  of  infants  at  birth; 
and  the  skin  itself  was  rosy,  and  of  a healthy  look.  The  extremities  were 
distinct,  but  short  and  thick;  the  fingers  and  toes  were  furnished  with 
nails  ; there  was  a well-formed  penis,  and  a cleft  scrotum.  There  was 
no  brain,  nor  spinal  marrow,  nor  diaphragm ; neither  heart,  nor  liver,  nor 
urinary  organs,  nor  any  internal  organs  of  generation.  Scarcely  any 
muscular  fabric  was  discovered  in  the  whole  mass.  The  alimentary 
canal  was  the  most  perfectly  formed  of  the  internal  organs;  a part  of  the 


MONSTERS. 


443 


intestines,  indeed,  was  in  all  respects  naturally  constructed.  Mr.  High- 
more,  a surgeon  of  Sherbourne  in  Dorsetshire,  opened  the  body  of  a boy 
named  Thomas  Lane,  between  fifteen  and  sixteen  years  old,  in  June  1814, 
in  which  he  found  the  rudiments  of  a human  foetus.  The  two  last-men- 
tioned specimens  are  preserved  in  the  Museum  of  the  College  of  Sur- 
geons. 

In  VHistore  de  VJlcad6mie  Roy  ale  des  Sciences , vol.  ii.  p.  298,  1733, 
there  is  an  account  given  by  M.  de  Saint  Donat,  a surgeon  at  Sisterton, 
of  a foetus  found  in  the  scrotum  of  a man.  And  Velpeau  presented  to 
the  Paris  Academy,  in  1840,  a preparation  of  the  rudiments  of  a foetus 
— the  whole  mass  being  as  large  as  a doubled  fist — which  he  had  removed 
from  its  connexion  with  the  right  testicle  of  a man,  set.  27,  named 
Gallochat.  The  tumour  had  existed  from  his  birth,  and  had  increased 
up  to  the  time  when  he  was  three  or  foar  years  old. — (See  Gazette 
Medicale,  Feb.  15th,  1840;  copied  into  the  London  Medical  Gazette , 
March  13th,  1840.) 

Parts  misshapen , though  properly  situated,  are  by  no  means  uncommon; 
sometimes  this  unnatural  formation  is  the  result  of  defective,  sometimes 
redundant  organization ; thus  the  different  features  of  the  face  may  be 
malformed ; the  scrotum  is  sometimes  cleft ; the  urethra  and  rectum  im- 
perforate. Club  feet  are  usually  classed  among  this  variety  of  monstrosity; 
but  it  appears  to  me  that  they  often  owe  their  origin  to  accidental  causes 
rather  than  natural  formation.  The  distortion  may  not  unfrequently  arise 
from  the  limb  being  cramped  in  utero,  owing,  perhaps,  to  the  awkward 
position  in  which  the  child  lies,  or  to  there  being  but  a small  quantity  of 
liquor  amnii. 

Misplacement  of  perfectly  formed  parts  is  the  least  common  of  all  kinds 
of  monsters.  I do  not  know  that,  even  among  all  the  extravagant  stories 
in  the  older  works,  there  is  any  account  of  a well-formed  arm  arising  from 
the  pelvis,  or  a leg  from  the  scapula ; and  we  should  certainly  not  give 
credence  to  it,  were  we  to  meet  with  such  a tale.  But  the  viscera  have 
been  transposed ; and  such  a case  may  be  considered  a monstrosity  of 
of  this  description.  The  most  perfect  on  record,  perhaps,  is  given  by  Dr. 
Bailie,  in  the  Philosoph.  Trans.,  vol.  lxxviii.,  for  1788.  A foetus  with  the 
heart  on  the  right  side,  and  other  viscera  transposed,  is  preserved  in  the 
London  Hospital  Museum ; the  subject  was  in  other  respects  misformed. 

It  may  be  thought  a needless  waste  of  time  to  enter  so  much  at 
large  upon  subjects  from  which  no  practical  good  appears  likely  to 
result;  but  its  interest  has  seduced  me  into  these  details.  Besides, 
by  studying  nature  in  her  imperfections  and  irregularities,  we  are  more 
likely  to  arrive  at  some  knowledge  of  her  laws,  than  if  we  regard  her 
only  in  her  healthy  condition.  By  learning  what  parts  she  can  dispense 


444 


COMPLEX  LABOURS. 


with,  we  ascertain  those  organs  essential  to  existence ; and  by  tracing 
the  deviations  from  her  common  course,  we  may  perhaps  be  hereafter  led 
to  a more  correct  acquaintance  with  her  methodus  agendi. 

Origin. — It  is  not  my  intention  to  endeavour  to  account  for  the  origin 
of  monstrous  formations ; but  I may  cursorily  state,  with  regard  to  de- 
li cient  and  redundant  monsters,  that  some  suppose  the  germ,  before  im- 
pregnation, is  improperly  formed ; others,  that  it  is  an  undue  admixture  of 
prolific  particles  at  the  moment  of  fecundation ; others,  that  monstrosity 
has  taken  place  after  conception,  owing  to  some  irregular  vascular  excite- 
ment, or  deficiency  of  nourishment ; — thus  the  vessels  of  the  redundant  part 
being  more  numerous,  and  more  active  than  they  ought  to  be,  produce  an 
excess  of  growth,  whilst  those  of  the  deficient  part  are  just  in  a contrary 
condition.  Where  a connexion  of  two  children,  nearly  or  quite  perfect, 
exists,  I cannot  help  thinking  that  union  takes  place  not  only  after  fecun- 
dation, but  after  the  foetuses  have  grown  to  a certain  size.  In  the  case  of 
the  Siamese  twins,  or  the  original  of  fig.  140,  Plate  LI.,  I presume  that  they 
were  originally  true  twin  conceptions,  but  that  the  membranes  which  ought 
to  have  enveloped  each  body,  so  as  to  form  an  inseparable  barrier  between 
them,  were  imperfect,  and  that,  in  consequence,  the  bodies  were  allowed 
to  come  into  close  contact  with  each  other ; that  there  is  such  a strong 
formative  power  existing  in  the  vascular  system  of  the  foetus,  that  when 
the  two  cuticular  surfaces  came  together,  vessels  shot  from  one  to  the 
other,  and  the  parts  became  permanently  united  by  adhesion,  in  the  same 
way  that  two  fingers  would  coalesce,  provided  the  skin  was  removed  and 
they  were  kept  in  apposition.  We  know  that  sometimes  twins  are  con- 
tained in  the  same  bag  of  membranes,  and  in  such  case,  provided  they  lay 
for  any  length  of  time  in  contact,  we  may  believe  it  quite  possible  for  a 
junction  of  the  two  bodies  to  occur. 

Richerand  tells  us,  “ by  placing  in  a confined  vessel  the  fecundated  ova 
of  a tench,  or  any  other  fish,  the  numerous  young  ones  which  are  formed, 
not  having  space  sufficient  for  their  growth,  adhere  to  each  other,  and 
fishes  truly  monstrous  are  produced.”  And  in  the  vegetable  kingdom  it 
is  not  very  unusual  for  two  fruits,  in  contact  and  cramped  in  their  growth, 
to  unite  indissolubly.  e ,|jj 

Treatment. — In  regard  to  the  management  of  these  anomalous  cases,  > 
which  is  the  chief  point  of  interest  to  the  obstetrical  surgeon,  I have  little  ^ 
to  offer.  It  is  very  possible  we  might  be  deceived  in  mistaking  the  pre- 
sentation of  the  head  of  an  acephalous  child  for  some  other  part,  or  we 
might  be  quite  at  a loss  to  make  out  what  it  was.  Under  such  circum- . 
stances,  as  accurate  an  examination  as  possible  of  all  the  body  within 
reach  should  be  instituted,  and  probably  one  or  other  of  the  features  fp 
might  be  felt,  which  would  lead  us  to  a correct  diagnosis.  If  the  foetus  ' 


MONSTERS. 


445 


be  deficient  in  the  size  of  any  part/  or  in  its  members,  without  a corre- 
spondent enlargement  of  bulk  in  other  organs,  no  interference  can  be 
required,  provided  the  pains  be  strong,  and  the  pelvis  sufficiently  roomy  ; 
but  if  it  be  double,  Plate  XLI.  fig.  140  and  141,  or  excessive  in 
development,  the  common  principles  before  laid  down  must  guide  us. 
The  varieties  of  monstrous  formations  in  excess  are  so  many  and  diversi- 
fied, that  it  is  utterly  impossible  to  lay  down  rules  to  meet  all  exigencies. 
The  conduct  of  the  case,  therefore,  must  be  left  entirely  to  the  judgment 
of  the  practitioner ; and  the  welfare  of  his  patient  will  depend  on  the 
correctness  of  the  views  he  has  formed  of  natural  and  instrumental  deli- 
very, and  on  the  dexterity  he  may  have  acquired  by  practice. 


10th.  LABOURS  COMPLICATED  WITH  PLURAL  BIRTHS. 

Women,  although  usually  uniparient,  like  other  uniparient  animals, 
sometimes  produce  more  than  one  offspring  at  a birth ; and  when  the  ges- 
tation is  plural,  twins  are  by  far  the  most  frequent.* 

It  is  popularly  supposed  that  climate,  and  the  state  of  civilization  to 
which  the  country  has  advanced,  exert  an  influence  on  the  multiplication 
of  the  human  species ; and  that  certain  external  circumstances  are  favour- 
able or  otherwise  to  the  frequent  production  of  twins ; but  this  is  by  no 

* The  average  of  twin  cases  varies  considerably  in  different  parts  of  the  world  ; and  we  find 
also  no  little  difference  in  the  tables  kept  by  separate  individuals  in  the  same  country.  Thus 
Denman  shows  that  in  the  Middlesex  Hospital  in  this  metropolis  one  occurred  in  about  every 
95  labours;  in  the  London  practice  of  midwifery  the  estimate  is  stated  as  one  in  48;  Conquest 
considers  it  one  in  90;  Gooch,  one  in  about  70;  Blundell  states,  that  from  the  statistical  ac- 
counts transmitted  to  government  in  the  year  1801,  it  appeared  that  in  these  islands  one  in  65 
was  a twin  case.  Bland  in  London,  and  Boer  at  Vienna,  found  the  average  one  in  80 ; in  the 
Maternity  at  Paris,  one  was  met  with  in  88 ; in  the  Maison  d’Accouchemens,  one  in  91 ; Mad. 
Boivin  met  with  one  only  in  every  132  ; Dewees  averages  the  frequency  in  North  America  as 
one  in  75  ; Dr.  Arnell’s  average  is  also  one  in  75;  Dr.  Moore’s,  one  in  76.  From  Collins’  table, 
of  129,172  women  delivered  in  the  Dublin  Lying-in  Hospital,  there  were  2,062  cases  of  twins, 
being  one  in  about  every  62  labours;  29  of  triplets,  or  one  in  4,450  and  one  of  quadruplets. 
From  tables  which  I have  myself  kept,  I find  that  out  of  29,489  cases  that  occurred  in  the 
> Royal  Maternity  Charity,  from  January  1st,  1828,  to  December  31st  1840,  there  were  318  in. 
'^stances  of  twins,  or  one  in  nearly  every  93  labours.  Of  these,  114  were  of  different  sexes  ; 93 
i » Wfcfre'both  boys;  and  111  both  girls  ; — 141  of  these  children  presented  both  with  the  head;  131, 
the  head  and  breech,  or  lower  extremities  ; 29,  both  breech  or  lower  extremities ; 14,  one  head, 
one  transversely;  2,  one  breech,  the  other  transversely;  and  in  one  both  presented  transversely. 
It  is  curious,  too,  that  when  the  children  were  of  different  sexes  they  mostly  presented  with 
the  head  and  breech.  Triplets  are  generally  supposed  to  be  met  with  once  in  about  3 or  4,000 
labours  ; and  the  returns  from  Dublin  would  lead  us  to  believe  that  estimate  tolerably  correct ; 

. but  I am  inclined  to  think  the  frequency  of  these  cases  generally  much  overrated,  for  out  of 
these  29,489  births  there  was  but  one  case  of  triplets.  Quadruple  cases  are  so  rare  as  to  defy 
4ny  thinglike  an  accurate  calculation. 


446 


COMPLEX  LABOURS. 


means  proved  ; .although  we  know  that  some  animals,  the  sow  for  instance, 
farrow  more  young  at  a birth,  and  also  more  frequently,  when  domesti- 
cated, than  when  in  a state  of  nature.  Dewees*  says,  that  if  the  various 
tables  can  be  relied  on,  it  is  certain  “ there  are  conditions  and  circum- 
stances which  give  rise  to  more  double  births”  in  America  than  Europe ; 
while  Collinsf  remarks,  “ it  is  singular  that  in  Ireland  the  proportional  num- 
ber of  women  giving  birth  to  twins  is  nearly  a third  greater  than  in  any 
other  country  from  which  I have  been  able  to  obtain  authentic  records. ”J 

It  is  also  a belief  that  preternatural  fecundity  is,  to  a certain  extent,  he- 
reditary ; and  Dewees  states,  that  “ some  facts  within  his  own  knowledge 
would  seem  to  countenance  this  supposition : but  they  are  not  sufficiently 
numerous  or  strong  to  confirm  it.”  He  looks  upon  it,  however,  as  in  some 
instances  constitutional,  and  adduces  the  case  of  a woman,  whom  he  knew, 
that  five  times  produced  twins,  and  never  had  a single  child ; and  another 
who  thrice  brought  forth  twins,  though  not  consecutively. § 

It  has  been  observed,  indeed,  that  some  seasons  appear  more  prolific 
than  others,  as  well  in  the  human  race  as  other  productions  of  nature;  but 
whether  this  is  quite  accidental,  or  dependent  on  some  fixed  laws,  is  not 
easily  determined.  Denman  thinks  “ it  can  scarcely  be  doubted  that  there 
is  some  relation  in  those  years  between  the  animal  afid  vegetable  creation.” 

Rare  as  instances  of  quadruplets  are,  the  prolific  powers  of  the  human 
female  are  not  even  limited  to  the  production  of  four  children  at  a birth. 
In  the  Museum  of  the  College  of  Surgeons  in  this  city,  there  are  five 
foetuses  preserved  which  were  expelled  at  one  birth,  under  the  care  of  the 
late  Dr.  Hull  of  Manchester ; they  had  advanced  to  five  months  intra-ute- 
rine  age.|| 

In  the  London  Practice  of  Midwifery,  which  is  a copy  of  the  late  Dr. 

* Parag.  1321.  + Pract.  Treatise,  p.  309. 

t I have  heard  these  two  opinions,  apparently  contradictory,  attempted  to  be  reconciled  by 
the  explanation  that  a large  proportion  of  the  first  European  emigrants  to  America  were  from 
the  Emerald  Isle.  Denman,  too,  (chap.  xvii.  sect.  1,)  thinks  climate  and  the  state  or  degree 
of  civilization  have  their  influence  over  the  fecundity  of  human  beings. 

§ Gottlob  mentions  one  who  in  three  births  produced  eleven  children. — (Elliotson’s  Notes 
to  Blumenbach,  p.487.) 

||  There  are  several  other  well-attested  cases  of  five  children  at  a birth.  One  will  be  found 
in  the  Gentleman’s  Magazine  for  1736 ; the  patient  lived  in  the  Strand ; another,  in  the  same 
periodical,  1739,  at  Wells,  Somersetshire;  one  occurred  in  Upper  Saxony  ; one  near  Prague  in 
Bohemia,  (Garthshore,  Philosoph.  Trans.,  1787.)  Chambon  relates  a case  of  five,  which  lived 
long  enough  to  be  baptized,  (Campbell’s  Mid.,  p.  291.) 

In  the  British  and  Foreign  Med.  Review  for  1839,  a notice  is  given  of  a woman  at  Naples 
being  delivered  of  five  children  at  seven  months  ; in  the  Dublin  Med.  Journal  for  January  1840, 
there  is  an  account  given  of  Dr.  Evory  Kennedy  having  shown  to  the  Dublin  Pathological 
Society  five  ova  of  between  two  and  three  months,  which  were  expelled  at  once  under  the  su- 
perintendence  of  Dr.  Thwaites.  They  were  all  male  children.  And  if  we  could  credit  news, 
paper  reports,  we  might  add  the  following  : — The  wife  of  a cannon-founder  at  Luginski  in 


PLURAL  BIRTHS. 


*147 


John  Clarke's  lectures,  and  some  other  works  on  the  science,  it  is  stated 
that  Dr.  Osborn  met  with  six  distinct  ova  thrown  off  at  one  abortion,  but  on 
what  authority  I have  not  been  able  to  discover.* 

When  there  is  more  than  one  foetus  in  utero,  each  is  generally  smaller 
than  in  single  births ; and  in  proportion  to  the  number  will  the  size  of  the 
children  be  less.  Thus  Dr.  Joseph  Clarke’s  estimate  of  the  weight  of  twins 
is  twelve  pounds  and  a half  the  pair.  We  often  remark  also  that  in  twin 
gestations  one  foetus  at  birth  is  sensibly  smaller  than  the  other.  Should 
the  uterus  contain  more  children  than  two,  the  woman  seldom  carries 
them  to  the  full  term,  and  they  are  consequently  rarely  reared.  On  the 
subject  of  Plurality,  a curious  and  learned  paper  by  Garthshore,  Philosophi- 
cal Trans,  vol.  Ixxvii.  p.  344,  June,  1787,  may  be  consulted. 

Twins  may  possibly  proceed  both  from  one  ovarium,  or  the  rudiments 
of  one  foetus  may  be  furnished  by  each  gland.  When  the  conception, 
however,  is  more  than  duplex,  it  is  clear  that  one  ovary  must  supply  two; 
for  no  instance  has  yet  been  met  with,  where  these  organs  were  in  excess. 
It  is  commonly  supposed  that  twins  are  the  result  of  one  connexion ; and 
instances  are  noted  where  this  must  have  been  the  case.  But  it  is  not 
equally  plain  that  this  is  a universal  rule;  and  it  appears  to  me  by  no 
means  impossible  that  a second  impregnation  may  take  place  soon  after  a 
former  one  has  occurred.  It  is  not  difficult,  indeed,  to  imagine  that  such 
an  event  may  happen  at  any  time  previously  to  the  uterus  becoming  lined 
with  the  secretion  afterwards  converted  into  the  deciduous  membrane,  or 
until  its  mouth  is  plugged  with  that  viscid  mucus  which  divides  its  cavity 
from  that  of  the  vagina,  and  which,  after  its  formation,  would  entirely 
prevent  the  immission  of  the  seminal  fluid  in  coitu.\ 


Russia  was  delivered,  on  May  22nd,  1836,  of  five  girls,  of  whom  four  were  living  and  likely 
to  do  well.  (Satirist,  Aug.  7,  1836.)  The  Giornale  del  Due  Sicilie  states,  that  a woman  was 
safely  delivered,  on  June  21,  1838,  of  a boy  and  four  girls;  ail  of  whom  died  at  the  expiration 
of  half  an  hour.  (Times,  July  23, 1838.)  The  wife  of  a landed  propietor  at  Altruitweida,  near 
Mitweida,  in  Saxony,  was  recently  delivered  of  five  daughters,  who,  though  perfect  in  their 
conformation,  died  in  about  half  an  hour  after  their  birth.  (Times,  Aug.  29,  1838.)  So  that 
Dr.  Hull’s  case  is  by  no  means  without  a parallel. 

* My  father,  who  was  a pupil  of  Dr.  Osborn’s  for  some  time,  and  on  terms  of  friendship 
with  him,  has  no  recollection  of  ever  having  heard  him  mention  such  a circumstance.  Pare, 
(lib.  xxv.  chap.  3,)  tells  us,  that  in  his  day  the  wife  of  the  Lord  of  Maldemeure,  in  the  parish 
of  Sceaux,  near  Chambellay,  produced  six  children  at  a birth,  after  which  she  died ; and  that 
the  then  present  Lord  of  Maldemeure  was  the  only  surviving  one.  His  history  of  this  extraor- 
dinary occurrence  is  so  circumstantial,  as  to  impress  us  with  the  belief  that  he  was  himself 
fully  convinced  of  the  fact.  It  would  be  going  too  far,  perhaps,  to  say  that  such  an  event  was 
impossible : but  we  must  take  into  account  that  Pare,  though  an  honest  man,  and  excellent 
surgeon  for  his  time,  was  a very  credulous  philosopher. 

t Cases  are  recorded  that  bear  upon  this  point.  The  celebrated  one  related  by  Buffon,  for 


448 


COMPLEX  LABOURS. 


Each  individual  child  which  the  uterus  contains,  according  to  the  law 
of  nature,  is  distinctly  enveloped  in  its  own  membranes, — so  that  its  body 
is  not  in  contact  with  that  of  its  brother, — possesses  its  own  quantity  of 
liquor  amnii,  has  a separate  funis  and  separate  placenta, — the  circulations 
not  inosculating.  Generally  the  placentas  are  attached  together  at  a part  of 
their  edges ; Plate  XVIII.  fig.  63 ; and  often,  on  regarding  the  maternal  face, 
they  appear  but  one  mass ; at  other  times  they  are  situated  distantly  from 
each  other,  at  different  points  of  the  uterus ; again,  occasionally,  though 
very  rarely,  the  vessels  of  the  one  child  anastomose  with  those  of  the 
other.  It  has  been  remarked,  that  both  children  have  lain  in  one  bag 
of  membranes;  and  cases  are  recorded,  where  the  placenta  was  in 
all  respects  single,  and  the  funis  also  arose  singly,  and  divided  into  two 
branches  when  about  to  terminate  in  the  umbilicus  of  each  foetus. 

Symptoms  of  twin  gestation . — There  are  no  symptoms  during  pregnancy 
which  positively  indicate  to  us  that  the  womb  contains  more  than  one 
foetus.  Some  have  been  noted  and  dwelt  upon  as  diagnostic  marks,  but 
they  are  all  more  or  less  fallacious.  Such  are,  the  uterus  being  of  a 
larger  size  than  usual;  but  this  may  depend  on  an  increased  quantity  of 
liquor  amnii ; — the  woman  feeling  two  distinct  movements  at  different 
parts  of  the  uterus ; but  the  sensations  of  a pregnant  patient  on  this  point, 

example,  (Nat.  Hist.  vol.  ii.  p.  433,  trans.)  A white  woman  at  Charlestown,  South  Carolina, 
was  delivered,  in  1714,  of  two  children,  one  black,  and  the  other  white; — this  difference  in 
colour  led  to  an  inquiry,  and  she  confessed  that,  on  a particular  day,  immediately  after  her 
husband  had  left  his  bed,  a negro  entered  her  room,  and  threatening  to  murder  her  if  she  did 
not  consent,  forced  her  to  submit  to  his  will.  Dr.  Mosely  has  recorded  another  instance  some- 
what similar;  (Tropical  Diseases,  p.  Ill ;)  it  occurred  within  his  own  knowledge,  on  Shortwood 
Estate,  Jamaica.  A negro  woman  brought  forth  at  a birth  two  children  of  the  same  size,  one 
of  which  was  a negro,  and  the  other  a mulatto.  On  being  questioned,  she  admitted  that  a 
white  man  belonging  to  the  estate  came  into  her  hut  one  morning  before  she  was  up,  and  she 
suffered  his  embraces,  almost  immediately  after  her  black  husband  had  left  her.  Dr.  Dewees 
(Philadelphia  Med.  Museum,  vol.  i.)  has  related  that  a servant  in  Montgomery  county  was  de- 
livered of  a black  and  white  child  at  one  birth,  which  were  often  seen  by  the  doctor.  He  states 
also,  that  on  the  report  of  her  pregnancy,  both  a black  and  white  man  disappeared  from  the 
neighbourhood;  and  Elliotson  (Notes  to  Blumenbach,  p.  485)  has  put  on  record,  that  Mr,  Black- 
aller  of  Weybridge  sent  him  the  following  account: — A white  woman  of  very  loose  character 
left  her  husband,  and  some  time  afterwards  returned  pregnant  to  the  parish,  and  was  delivered 
in  the  workhouse  of  twins;  “one  of  which,”  says  Mr.  Blackaller,  “was  born  of  a darker  co- 
lour than  I have  usually  observed  the  infants  of  the  negroes  in  the  West  Indies  to  be;  the  hair 
quite  black,  with  the  woolly  appearance  usual  to  them,  with  flat  nose  and  thick  lips  ; the  other 
had  all  the  appearances  common  to  white  children.”  That  these  respective  twins  were  not 
the  offspring  of  one  parent  is  very  evident;  and  a second  impregnation,  therefore  must  have 
taken  place;  but  we  have  proof  in  two,  at  least,  that  the  connexions  followed  each  other  quickly, 
before  any  changes  could  have  been  commenced  in  the  uterus.  With  the  knowledge,  then,  of 
such  accidental  occurrences  in  our  possession,  we  are  warranted  in  believing  that,  in  the  case 
of  a woman  living  with  her  husband,  twins  might  possibly  be  the  result  of  two  separate  con- 
nexions, if  only  a short  period  intervened  between  them. 


pi.Ln 


Stric-lajj'lr 


TWIN  GESTATION. 


449 


as  expressed  by  her,  are  scarcely  ever  to  be  relied  upon ; — an  irregularity 
in  the  shape  of  the  womb ; its  being  broader  than  common,  or  measuring 
more  laterally  than  in  the  longitudinal  direction ; but  this  again  may  be 
the  consequence  of  a transverse  position  of  the  foetus,  or  an  irregularity 
in  the  development  of  the  uterine  fibres  themselves.  If,  indeed,  it  should 
happen  that  the  organ  was  divided  into  nearly  equal  portions,  by  a 
sulcus  running  longitudinally  downwards  from  the  fundus  to  the  cervix, 
we  might  suspect  a twin  gestation  with  some  confidence.  Collins,*  Ken- 
nedy,! Montgomery,!  and  other  practitioners  who  have  given  their  atten- 
tion to  auscultation,  as  a means  of  distinguishing  pregnancy,  inform  us, 
that  they  have  detected  twins  in  utero  by  the  double  pulsation  of  the  foetal 
hearts.  This  means  of  diagnosis  can  only  be  available  to  those  who  have 
acquired  considerable  tact  in  the  use  of  this  instrument ; and,  fortunately, 
such  knowledge  is  not  required  for  the  purpose  of  regulating  our  practice ; 
for  although  we  might  be  assured  of  the  gestatiorf  being  plural  before 
labour  commenced,  our  treatment  would  not  be  in  the  least  influenced  by 
our  discovery. 

Position  in  utero . — The  two  children  may  each  be  placed  in  utero  in 
all  the  varieties  of  position  which  one  may  occupy.  It  is  generally  be- 
lieved that  the  most  frequent  presentation  is  the  head  of  one  and  breech  of 
the  other,  as  depicted  in  Plate  LII.  fig.  142;  but  from  my  own  tables 
(p.  445)  I should  conclude  it  was  more  usual  for  both  the  heads  to  offer 
themselves  downwards.  Campbell^  also  states,  that  from  a register  of 
his  cases,  “ he  finds  both  the  foetuses  have  almost  always  presented  the 
vertex.” 

Progress  of  labour  and  treatment. — Twin  labour  generally  proceeds 
exactly  in  the  same  manner  as  though  there  was  but  one  child.  The 
pains  increase  in  frequency  and  strength,  the  membranes  protrude  through 
the  os  uteri,  and  in  process  of  time  burst ; but  the  uterine  contractions  are 
often  more  feeble  than  when  the  womb  contains  but  one;  and  they  do  not 
seem  so  effective,  since  the  upper  ovum  being  interposed  between  the  con- 
tracting fibres  of  the  fundus,  and  the  foetus  which  is  presenting,  the  organ 
must  necessarily  expend  fruitlessly  no  small  portion  of  its  power.  No 
interference,  however,  is  necessary,  solely  on  that  account ; and,  provided 
nothing  untoward  happens,  the  labour  must  be  allowed  to  proceed  unin- 
terruptedly, until  the  first  child  is  expelled ; when,  for  the  first  time, — 
although  we  might  have  had  our  suspicions  before, — we  become  positively 
certain  of  the  existence  of  a second. 

I have  already  advised,  that  in  all  cases  the  hand  of  the  attendant  should 
be  placed  on  the  abdomen  as  soon  as  the  funis  is  divided,  to  ascertain  the 

* Pract.  Treatise,  p.  310.  t On  Pregnancy  and  Auscultation,  p.  129, 

t On  the  Signs  and  Symptoms  of  Pregnancy,  p.  126.  § System  of  Midwifery,  p.  293. 

57 


450 


COMPLEX  LABOURS. 


state  of  the  uterus  and  placenta,  and  to  learn  whether  there  be  a second 
child ; if  so,  the  womb  will  be  found  still  large, — its  fundus  rising  to  the 
umbilicus,  or  above  it, — and  occupying  a space  apparently  almost  as  great 
as  before  the  birth  of  the  first.  We  may  detect,  also,  that  degree  of  elas- 
ticity and  subdued  fluctuation, — if  the  membranes  be  still  whole, — which 
are  so  characteristic  of  the  uterus  at  full  time.  This  simple  examination 
will  generally  be  sufficient  to  inform  us  of  the  fact ; should  any  doubt,  how- 
ever, remain,  the  finger  must  be  passed  up  to  the  os  uteri,  and  the  mem- 
branes of  the  second  foetus  will  be  felt  protruding,  as  during  the  first 
stage  of  natural  labour. 

It  is  possible,  however,  that  we  may  be  deceived  both  in  the  external 
and  internal  examination.  The  uterus  may  contain,  besides  the  placenta, 
a large  quantity  of  coagula,  which  may  so  distend  its  cavity,  that  the 
organ  may  occupy  the  principal  part  of  the  abdomen;  but  it  will  be  softer 
than  when  another  child  remains ; and  on  pressure  being  applied,  blood 
will  most  likely  be  squeezed  through  the  vagina.  Again,  a collection  of 
blood  behind  the  membranes  of  the  retained  placenta  may  be  mistaken  for 
the  unbroken  cyst  of  a second  child.  The  case  will  be  rendered  clear  on 
lacerating  them ; for  coagula  and  fluid  blood  will  escape  instead  of  liquor 
amnii. 

As  soon  as  we  have  satisfied  ourselves  that  the  case  is  plural,  it  is  our  duty 
to  determine  the  presentation  of  the  second  child  as  speedily  as  possible; 
and  if  it  be  transverse,  to  turn,  as  in  ordinary  cases,  according  to  the 
rules  already  sufficiently  detailed.  But  if  the  head  or  breech  be  present- 
ing, the  membranes  may  be  ruptured  immediately,  that  an  opportunity 
may  be  given  for  the  depending  part  to  pass  at  once  into  the  pelvis.  There 
cannot  be  the  same  necessity  for  preserving  the  bag  of  membranes  of  a 
second  foetus  entire  that  exists  in  single  births,  because  the  passages  have 
been  sufficiently  prepared  by  the  exit  of  the  first  to  allow  the  easy  transit 
of  the  second,  if  the  children  are  nearly  of  the  same  size ; and  this  pro- 
ceeding frequently  excites  the  uterus  to  increased  energy,  and  facilitates 
the  termination  of  the  case. 

It  will  occasionally  happen,  indeed,  that  the  two  children  are  expelled 
so  rapidly,  one  after  the  other,  as  scarcely  to  give  time  for  an  internal  ex- 
amination to  be  instituted  between  their  births ; and  it  has  occurred  to  me 
more  than  once  to  find  a second  child  in  the  world  before  the  one  already 
born  could  be  separated. 

If  the  uterine  contractions  be  tolerably  powerful,  the  birth  of  a second 
twin  is  very  seldom  protracted,  unless  it  be  misplaced  in  utero,  monstrous 
in  formation,  or  much  larger  in  size  than  the  one  first  expelled.  It  is  not  un- 
likely, however,  that  twins  may  exist  with  a deformed  pelvis,  and  both 
may  require  to  be  extracted,  either  by  the  forceps  or  craniotomy  instru- 


MANAGEMENT  OF  TWIN  LABOUR. 


451 


ments.*  Women,  then,  seldom  suffer  much  during  the  birth  of  a second 
twin.  As  the  principal  pains,  under  ordinary  labour,  are  those  of  dota- 
tion, and  the  sufferings  generally  in  proportion  to  the  resistance  experi- 
enced, we  should  naturally  expect  that  the  second  child  would  be  born 
without  either  any  great  effort  or  much  additional  painful  sensation.  But 
when  a woman,  after  having  given  birth  to  one  child,  learns  that  there  is 
another  still  in  utero,  she  mostly  becomes  not  only  apprehensive  for  her 
safety,  but  also  fearful  that  she  has  to  undergo  a repetition  of  the  agonies  she 
has  just  endured ; and  such  an  impression  on  her  mind  may  possibly  inter- 
fere with  the  due  continuance  of  uterine  action.  For  this  reason  it  is  better 
neither  to  inform  her  abruptly  of  the  nature  of  the  case,  nor  to  make  any 
mystery  about  it ; but  calmly  to  tell  her  that  she  will  soon  give  birth  to  a 
second ; and  this  may  be  coupled  with  a congratulation  on  the  fortunate 
progress  of  the  labour  so  far ; and  an  assurance  that  she  will  have  but 
little  more  pain  to  bear,  and  that  the  case  presents  no  features  calling  for 
anxiety. 

In  the  conduct  of  a common  twin  case,  it  is  of  the  greatest  consequence 
that  no  attempt  should  be  made  to  remove  the  placenta  of  the  first  until 
after  the  birth  of  the  second,  and  that  we  should  not  make  any  traction 
at  the  cut  funis  which  is  hanging  out  of  the  vagina ; for  if  we  separate  the 
placenta  from  its  uterine  attachment,  flooding  will  almost  certainly  super- 
vene, and  the  loss  of  blood  may  be  so  great  as  to  require  the  immediate 
evacuation  of  the  uterus ; the  only  likely  means  by  which  it  can  be  re- 
strained. 

Upon  the  expulsion  of  the  second  child,  the  uterus  must  be  again  ex- 
amined, both  externally  and  per  vaginam,  to  ascertain  that  there  is  not  a 
third,  the  birth  of  which  (should  there  be  another)  is  to  be  conducted  ex- 
actly on. the  same  principles;  so  likewise  with  regard  to  a fourth  and 
fifth ; for  any  practitioner  may  possibly  meet  with  one  of  these  prodigious 
instances  of  fecundity. 

In  every  case  of  plural  gestation,  there  is  considerably  greater  danger 
— particularly  from  hsemorrhage — than  when  the  birth  is  single ; and  this 
arises  partly  from  the  increased  size  which  the  uterus  has  acquired,  and 
its  indisposition  to  contract  thoroughly ; partly  from  the  larger  number  of 
vascular  orifices  exposed  on  the  separation  of  the  placentas;  and  partly 
from  the  greater  chance  of  adhesion  having  taken  place  at  some  part  of 
the  more  extended  surface  in  apposition  to  the  uterus.  Our  principal  at- 
tention should  therefore  be  directed  to  preventing  or  subduing  flooding. 

* Denman  (chap.  xvii.  sect.  3)  remarks,  “ If  we  were  compelled  to  make  the  first  labour 
artificial,  it  might  be  necessary  or  expedient  to  deliver  the  patient  of  her  second  on  the  same 
principle,  unless  the  natural  efforts  should  be  efficaciously  made  soon  after  the  birth  of  her 
first  child.”  This  as  a general  principle  of  action  will  perhaps  be  found  the  most  frequently 
applicable  ; but  there  must  exist  numerous  exceptions. 


452 


COMPLEX  LABOURS. 


With  this  view  the  uterus,  should  be  stimulated  to  throw  off  the  pla- 
centae by  the  grasping  pressure  of  the  hand,  and  the  utmost  care  must  be 
taken  that  both  these  masses  pass  from  the  cavity  at,  or  nearly  at  the 
same  time.*  Compression  on  the  uterine  tumour,  then,  must  be  used  more 
diligently  than  in  common  labours ; and  on  examining  internally,  to  ascer- 
tain whether  the  placentae  be  separated  and  lying  loose  in  the  vagina,  one 
of  the  funes  must  be  twisted  round  two  or  three  fingers  of  the  left  hand, 
and  brought  to  its  bearing,  while  the  index  of  the  right  is  carried  to  the 
brim  of  the  pelvis ; and  afterwards  the  other  must  be  treated  in  the  same 
way.  No  attempt  must^on  any  account,  be  made  to  extract  them  through 
the  agency  of  the  cords,  until  the  beds  of  both  can  be  most  distinctly  felt, 
and  the  principal  part  of  their  bulk  surrounded  by  the  finger,  introduced 
as  in  a common  examination ; but  when  they  have  descended  sufficiently 
low  to  be  entirely  encompassed, — each  funis  having  been  put  slightly  on 
the  stretch, — traction  may  be  made  by  both  together,  and  the  organs 
removed  from  the  vagina,  with  the  cautions  before  sufficiently,  I trust, 
insisted  on.  Should  flooding  supervene  after  the  birth  of  both  children, 
or  the  time  previously  specified  elapse,  the  hand  must  be  introduced,  and 
the  placentae  withdrawn ; should  adhesion  exist,  the  separation  must  be 
conducted  on  the  common  principles — care  being  taken  not  to  remove 
either  until  both  are  fully  in  our  grasp.  The  uterus  must  be  stimulated  to 
continued  contraction  by  pressure,  the  application  of  cold  and  astringents 
if  necessary ; and  the  case  must  be  treated  as  one  of  ordinary  haemor- 
rhage. On  the  withdrawal  of  the  placentas,  it  is  always  desirable  that  the 
maternal  face  should  be  inspected,  to  assure  ourselves  that  no  part  remains 
within  the  womb. 

I need  scarcely  warn  my  reader  that  if  flooding,  convulsions,  or  other 
dangerous  symptoms,  show  themselves  between  the  birth  of  the  two  chil- 
dren, the  ordinary  methods  must  be  used  to  combat  them,  and  the  delivery 
of  the  second  must  be  undertaken  as  speedily  as  is  consistent  with  safety. 
But  there  is  a point  admitting  of  some  dispute,  and  deserving  of  very  grave 
consideration — namely,  the  length  of  time  that  it  would  be  desirable  to 
wait  after  the  birth  of  the  first  child,  before  means  are  taken  to  extract  the 
second  ; no  dangerous  symptoms  appearing  in  the  interval.  Some  prac- 
titioners decry  artificial  assistance,  merely  in  consequence  of  lapse  of 
time,  and  found  their  arguments  on  the  very  excellent  obstetrical  maxim 
that  Nature  should  never  be  interfered  with,  or  thwarted  in  her  intentions, 
so  long  as  she  can  be  safely  trusted.  The  consequence  of  this  doctrine ' 
is,  that  often  many  hours,  sometimes  many  days,  have  been  allowed  to  pass, 

* Sometimes  one  of  the  placentae  will  pass  away  while  the  second  child  remains  in  utero, 
without  any  serious  haemorrhage  being  produced,  and  Collins  (p.  312)  mentions  four  cases  of 
this  kind  that  happened  under  his  own  eye.  But  this  is  unusual,  and  the  practice  recom- 
mended in  the  text  is  that  inculcated  by  all  modern  authors. 


MANAGEMENT  OF  TWIN  LABOUR. 


453 


after  the  birth  of  one  child,  before  the  labour  was  terminated.  This  is  a 
practice  that  I cannot  sanction,  because  of  the  danger  to  which  the  woman 
must  be  more  or  less  subjected  during  the  interval ; and  because  of  the 
anxiety,  excitement,  and  alarm,  that  must  necessarily  harass  her  mind  until 
she  is  relieved : nor  is  it  by  any  means  improbable  that  such  depressing 
feelings  may  materially  interfere  with  her  ultimate  recovery.  I therefore 
perfectly  concur  with  Denman  in  thinking,  that  if  uterine  action  is  not 
re-established,  some  limit  should  be  placed  to  our  passive  treatment,  and 
that  the  time  which  “ it  may  be  expedient  to  wait  shall  neither  be  so  short 
as  to  run  the  risk  of  injuring  the  patient  by  hurry  or  rashness,  nor  so  long 
as  to  increase  the  danger,  should  any  exist,  nor  the  difficulty  of  delivering 
the  patient,  if  we  should  be  at  length  obliged  to  use  art  for  this  purpose.” 
And  I think  the  period  specified  by  the  same  estimable  physician — four 
hours  perhaps — the  least  objectionable.*  I have  already  advised  that  the 
membranes  should  be  ruptured  soon  after  the  birth  of  the  first  child,  and 
the  possibility  of  being  compelled  to  deliver  artificially  does  not  militate 
against  this  practice  ; for  if  the  uterus  acts  vigorously,  the  foetus  will  most 
likely  pass  naturally ; and  if  the  pains  are  feeble,  or  altogether  deficient, 
there  can  exist  little  or  no  impediment  to  the  introduction  of  the  hand  and 
the  performance  of  turning : and  this  is  the  operation,  indeed,  which  we 
shall  find  most  usually  called  for,  when  it  becomes  necessary  to  terminate 
the  labour  by  art.  When  the  birth  of  the  second  child  is  retarded  by 
inertia,  a dose  or  two  of  the  ergot  may  sometimes  be  prescribed,  in  the 
hope  that  its  influence  over  the  uterus  will  occasion  such  efficient  action 
as  to  render  any  manual  interference  unnecessary ; but  if  the  specified 
time  have  elapsed,  and  our  expectations  be  disappointed,  we  should  not 
delay  resorting  to  more  certain  means  of  finishing  the  delivery.  These 
recommendations,  however,  must  only  be  understood  to  apply  to  twin 
labours,  at  the  full  period  of  gestation.  If  one  foetus  be  thrown  off  prema- 
turely, and  another  be  retained  in  the  womb,  it  would  be  unwise  to  rup- 
ture the  membranes  or  extract  manually — unless,  indeed,  the  immediate 
preservation  of  the  mother  required  the  emptying  of  the  cavity ; — because 
it  is  not  improbable  that  gestation  might  be  carried  on  for  the  perfection 
of  the  one  remaining,  and  it  would  be  our  duty  to  save  it,  even  at  the 
sacrifice  of  inflicting  much  personal  inconvenience  on  the  mother,  or  at 
some  small  risk  to  her. 

Cases  have  been  known,  indeed,  where  one  foetus  and  placenta  have 
both  been  expelled  prematurely,  and  the  other  retained  and  carried  until 
the  completion  of  the  period  of  gestation ; and  this  without  the  patient  suf- 
fering any  dangerous  loss  of  blood. 

It  is  seldom  that  the  membranes  of  both  ova  break  before  the  first  child 


* Chap.  xvii.  sect.  3.  Collins,  p.  311,  thinks  it  not  wise  to  wait  beyond  two  hours. 


454 


COMPLEX  LABOURS. 


is  expelled,  but  such  cases  #re  occasionally  met  with,  and  instances  are 
recorded  in  which  parts  of  two  separate  children  descended  into  the  pelvis 
together.  Thus  Dr.  Ferguson  of  Dublin  relates  (Med.  and  Phys.  Jour- 
nal, 1832,  vol.  lxvii.  p.  78)  a case  in  which  the  head  of  one  child  and 
the  feet  of  another  presented  at  the  same  time.  The  midwife  in  at- 
tendance, before  he  arrived,  had  pulled  down  the  feet,  and  jammed 
the  breech  and  head  together.  The  pains  being  very  powerful  the 
labour  was  terminated  naturally ; the  child  whose  head  presented  being 
expelled  first,  the  other  afterwards.  A case  very  similar  is  related  by  Mr. 
James  Alexander,  Jun.,  (Edinburgh  Med.  and  Surg.  Journ.,  Jan.  1822.) 
Mr.  Allan  (Med.  Chirurg.  Transactions,  vol.  xii.  p.  366,)  gives  us  another, 
in  which  the  heads  of  two  children  occupied  the  pelvis  together,  (the  body 
of  one  being  in  the  world,)  and  both  were  expelled  simultaneously  by 
uterine  contraction.  He  refers  to  another  also  of  the  same  kind  in  the 
Journal  de  Med.  for  Nov.  1771.  I was  on  one  occasion  sent  for  to  the 
assistance  of  a midwife  who  had  been  pulling  at  two  feet,  which  I found 
external  to  the  vulva.  Although  they  were  a right  and  left,  I immediately 
detected,  by  the  direction  of  the  toes,  that  they  belonged  to  different  bodies ; 
by  gently  pushing  up  one,  and  careful  traction  at  the  other  leg,  I extricated 
each  breech  from  the  brim  of  the  pelvis,  and  both  children  were  born 
living. 


CONCLUSION. 

I have  in  the  foregoing  pages  endeavoured  to  introduce  the  student  to 
an  acquaintance  with  the  principles  and  practice  of  obstetric  medicine,  in 
so  far  as  relates  to  the  process  of  parturition.  My  chief  object  has  been 
to  lay  down  well-established  principles  for  his  guidance  in  most  cases  of 
difficulty  and  anxiety,  deduced  either  from  my  own  experience,  or  from 
the  recommendation  of  authors  of  acknowledged  credit  and  authority.  I 
am  fully  aware  of  the  imperfections  and  omissions  with  which  the  work 
abounds ; but  as  I do  not  profess  to  offer  it  to  my  professional  brethren  as 
a finished  treatise,  and  as  my  intention  has  been  to  address  those  just  en- 
tering on  this  arduous  and  diversified  practice,  I trust  my  attempt  will 
meet  with  the  indulgence  generally  extended  to  all  who  strive  to  elucidate 
an  abstruse  and  comprehensive  subject.  It  may  be  considered,  perhaps, 
that  plural  births,  especially,  have  not  been  treated  of  as  largely  as  their 
importance  deserves ; but,  in  truth,  the  management  of  such  labours  does 
not  differ  essentially  from  our  duties  in  the  more  ordinary  cases;  and  I 
have  therefore  thought  it  better  to  be  concise,  than  to  fatigue  the  reader 
with  unnecessary  minuteness  and  tedious  repetition. 


INDEX 


Abdominal  presentation,  page  307 
Abscesses  in  pelvis  impeding  labour,  178 
Accidental  haemorrhage,  355 
After  treatment  of  labour,  143 
Amnion,  75 
Amnii  liquor,  76 
Animation,  suspended  foetal,  136 
Apoplexy  under  labour,  414 
Arm  presentation,  304 
amputation  of,  325 

Ascites,  foetal,  impeding  the  birth,  203 

Back  presentation,  306 
Bandage  after  labour,  145 
Bladder,  descent  of,  before  the  head,  181 
distended,  208 
rupture  of,  426 
Blood,  effects  of  loss  of,  394 
Blunt  hook,  250 
Bones  of  pelvis,  17 
of  foetal  head,  31 
Breech  presentation,  282 

management  of,  286 
difficult,  294 

distortion  of  the  pelvis  in,  296 
Brow  presentation,  155 

Caesarean  operation,  history  of,  262 

mode  of  performance,  263 
when  necessary,  40 
Carunculse  myrtiformes,  54 
Chorion,  75 

Cicatrix  in  the  vagina,  195 
Clitoris,  52 
Coccygis,  os,  23 
Collapse  in  labour,  428 


Complex  labours,  327 
Convulsions,  puerperal,  398 
causes  of,  402 
symptoms  of,  403 
prognosis,  416 
premonitory,  406 
treatment,  407 
hysterical,  414 
Cord,  umbilical,  see  Funis 
Corpora  lutea,  60 
Corpora  lutea,  false,  62 
Craniotomy,  248 

forceps,  250 
instruments  for,  249 
operation,  253 
Crotchet,  250 

guarded,  255 

Decapitation,  325 
Deformity  of  pelvis,  37 
Dorsal  presentation,  306 

Ear  presentation,  160 
Elbow  presentation,  305 
Ergot,  166 

Evolution,  spontaneous,  322 
Examination,  vaginal,  in  labour,  119, 121 
Exostosis  impeding  delivery,  176 
Exvisceration,  323 

Face  presentation,  158 
Fallopian  tubes,  64 
Fillet,  238 

Flooding,  see  Haemorrhage 
Fcetal  head,  anatomy  of,  see  Head 
Fontanelles,  32 


456 


INDEX. 


F<etus,  weight  of,  at  birth,  85 
position  of,  in  utero,  86 
expulsion  of,  109 
signs  of  death,  257 
controlling  growth  of,  in  utero,  268 
Foot  presentations,  292 
Forceps,  history  of,  213 

short  description  of,  214 
application  of,  216 
symptoms  requiring  the  use  of,  224 
long,  239 

description  of,  239 
application  of,  241 
craniotomy,  250 
Fourchette,  52 

Funis  umbilicalis,  anatomy  of,  81 
disease  of,  83 

Funis  umbilicalis,  coiling  of,  round  child’s 
neck  in  labour,  131 

tying  the,  134 
dividing,  134 
shortness  of,  204 
disrupted,  382 
prolapsus  of,  430 

Generation,  organs  of,  external,  51 
internal,  55 
Glands,  scirrhus,  in  pelvis,  178 
Graafian  vesicles,  60 

Hemorrhage,  uterine,  327 

symptoms  of,  332 
treatment  of,  334 
unavoidable,  338 
accidental,  355 
after  the  rupture  of  the 
membranes,  360 
after  the  child’s  birth,  361 
after  the  removal  of  the 
placenta,  385 
effects  of,  394 
Hand  presentation,  306 
by  the  head,  435 
Head,  fcetal,  anatomy  of,  31 
expulsion  of,  34 
presentation , marks  of,  124 
irregularities  of,  152 
dropsical,  199 
unusual  firmness  of,  202 
malposition  of,  152 
left  in  the  utero,  301 
Hook,  blunt,  250 
Hymen,  54 


Hymen,  unruptured  in  labour,  196 
Ilium,  os,  18 

Induction  of  premature  labour,  268 
Innominatum,  os,  17 
Instrumental  labour,  211 
Inversion  of  uterus,  383 
Irregularities  of  head  presentation,  152 
Ischium,  os,  19 

Knee  presentations,  191 

Labia  externa,  51 
interna,  53 
Labour,  natural,  89 

symptoms  of,  90 
classification  of,  99 
stages  of,  102 
duties  in  natural,  116 
after  treatment,  143 
lingering,  163 
causes  of,  164 
instrumental,  211 
premature  induction  of,  268 
lingering,  consequences  of,  276 
preternatural,  281 
complex  327 
Lacque,  see  Fillet 
Lever,  see  Vectjs 
Ligaments  of  the  pelvis,  27 
Ligaments,  broad , of  the  uterus,  59 
• round , ditto,  65 
Lingering  labour,  163 

causes  ofy  1 64 

inefficient  uterine  action,  165 
deformed  pelvis,  170 
pelvic  tumours,  170 
rigidity,  182 

disease  of  the  os  uteri,  184 
cicatrix  in  the  vagina,  195 
Lingering  labour,  unruptured  hymen,  196 
obliquity  of  os  uteri,  197 
preternaturally  tough  mem- 
branes 198 
dropsical  head,  199 
malposition  of  the  head,  202 
ascites,  foetal,  203 
tympanites,  ditto,  203 
shortness  of  funis  umbilicalis, 
204 

monstrosity,  206 


INDEX. 


457 


Lingering  labour,  management  of  a patient 
under,  207 

distended  bladder  under,  208 
consequences  of,  209 
Lochia,  character  of,  146 
Lutea,  corpora,  60 

false,  62 
Meatus  urinarius,  53 
Membrane,  deciduous,  72 
Membranes  of  the  ovum,  75 

spontaneous  rupture  of,  105 
toughness  of,  198 
Mons  veneris,  51 
Monstrosity,  206 

varieties  of,  437 

Nymphoe,  53 

Organs  of  generation,  external,  51 
internal,  55 

Osteotomist,  251 
Ovaries,  anatomy  of,  59 

enlargement  of,  impeding  delivery,  177 
Ovum,  membranes  of,  75 

Pains,  spurious,  96 
of  labour,  94 

Patient,  position  of,  in  labour,  121 
Perineum,  52 
Perineum,  rigidity  of,  192 
Placenta,  anatomy  of,  78 
twin,  80 
battledore,  81 
disease  of,  80 

natural  separation  of,  in  labour,  115 
expulsion  of,  115 
removal  of,  from  vagina,  139 
presentation,  338 
partial  ditto,  352 
retained,  366 
absorption  of,  365 
adhesion  of,  526 
disrupted,  535 
Pelvis,  bones  of,  17 
form  of,  24 
axes  of,  26 

joints  and  ligaments  of,  27 
muscles  within,  69 

difference  between  male  and  female,  28 
deformed,  37 
preternaturally  large,  48 
Pelvimeters,  45 

58 


Perforator,  obstetric,  250 
Perineum,  52 

mode  of  supporting,  in  labour,  129, 
132 

laceration  of,  130 
rigidity  of,  192 

Premature  labour,  induction  of,  268 
Preputium  clitoridis,  52 
Preternatural  labour,  281 
Polypi  in  pelvis  impeding  delivery,  179 
Position  of  patient  in  labour,  121 
Plural  births,  621,  667 
j Pubis,  os,  20 

section  of  symphysis,  266 
Pudendi  labia,  51 

Rigidity  of  the  os  uteri,  183 
from  disease,  184 
of  the  vagina,  192 
perineum,  192 
Rupture  of  the  uterus,  415 
vagina,  425 
bladder,  426 

Sacrum,  os,  22 

Scirrhus  glands  in  pelvis,  impeding  delivery, 
178 

ScYBALiE  impeding  parturition,  182 
Shoulder  presentation,  304 
Secale  cornutum,  see  Ergot 
Side  presentation,  306 
Sigaultean  operation,  266 
Skull,  fcetal,  see  Head 
Spine,  incurvated,  41 
Spontaneous  evolutions,  322 
Sternal  presentation,  307 
Suckling,  150 
Sutures  of  foetal  head,  32 
Symphysis  pubis,  section  of,  266 
Syncope,  labours  complicated  with)L428 

Transfusion,  391 
Transverse  presentations,  301 
Tubes,  Fallopian,  64 
Tumours  pelvic,  impeding  labour,  176 
Turning,  operation  of,  in  transverse  presenta- 
tions, 307 

in  placental  presentations,  344 
Twins,  average  frequency,  445 
Twin  gestation,  symptoms  of,  448 
labour,  management  of,  449 
Tympanitis,  foetal,  impeding  the  birth,  203 


458 


INDEX. 


Umbilical  cord,  see  Funis 
Umbilical  vesicle,  84 
Unavoidable  haemorrhage,  338 
Urachus,  83 
Urinarius  meatus,  53 
Uterus,  unimpregnated , anatomy  of,  56 
ligaments  of,  59 

Uterus,  unimpregnated , arteries  of,  66 
nerves  of,  67 

Uterus,  impregnated,  anatomy  of,  71 
development  of,  87 
rigidity  of  the  mouth  of,  183,  187 
obliquity  of,  197 
inversion  of,  382 
rupture  of,  415 
causes  of,  416 


Uterus,  impregnated , symptoms  of,  418 
premonitory,  424 
treatment  of,  421 

Vagina,  anatomy  of,  55 
rigidity  of,  192 
cicatrix  in,  195 
laceration  of,  425 
Vectis,  history  of,  231 

description  of,  231 
use  of,  232 

Vertex  presentation  in  labour,  152 
Vesicles,  Graafian,  60 
umbilical,  84 
Vestibule,  53 
Vulva,  52 


fiic  library  up 
SEP  2 5 193 4 
UNIVERSITY  Of  ILLINOIS 


